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How To Deal With Your HMO

Getting the best health care possible from an HMO or managed health care provider can be difficult. Here are some tips to insure you get the treatment you need.


  • Take advantage of managed care services aimed at prevention such as mammograms, flu shots, nutritional counseling, exercise classes, stress-reduction workshops, programs to help kick tobacco and discounts at health clubs. Many plans offer special options for women including programs to deal with menopause, as well as classes for pregnant women on birth, nursing, and parenting.
  • Know your rights. Usually these are listed in your documents, but you may not get all the details unless you ask. Take special note of your right to appeal a decision when treatment or payment is denied.
  • Many managed care plans require you to select a primary care physician who will coordinate all the care you receive through your plan. It is important to be thorough in your search. Many plans offer lists of doctors in your area, with information including their education, and board certifications. If your plan doesn’t offer this resource, you can find it at your local library’s Directory of Medical Specialists, which lists information on 400,000 physicians. Try to interview prospective doctors to get a feel for them. You should be confident that your doctor will fight for your care and be your advocate when you are sick. If the doctor you choose doesn’t work out, you should not feel hesitant to find a new one. The American Board of Medical Specialties can tell you whether doctors are board certified. Call them toll free at 800-776-2378.
  • Eventually you will probably have to go outside of your primary care doctor to see a specialist. In most managed care plans you have to get a referral from your doctor to see a specialist. If your plan requires it, make sure you get a written referral from your primary doctor before you see a specialist or else you might have to pay the entire bill yourself. Even though it’s an inconvenience, this can be beneficial since your doctor will have to discuss your care with the specialist and they can work together to treat you.
  • Take an active role in your health care. In traditional fee-for-service medicine, patients can often refer all health care decisions to their doctor without a problem, but in managed care you should be more assertive than you have been before. Patients who are involved in decisions about their health care are more likely to get care before an emergency develops.
  • Under managed care, doctors are more pressed for time, so you can make the most of your and your doctor’s time by knowing your medical history, writing down questions and symptoms you have, and taking notes or asking for written instructions to follow.
  • If you don’t agree with a recommendation, don’t be afraid to get a second opinion. Many plans pay for this, especially in cases of potentially expensive or risky procedures.
  • Most plans have “formularies,” or lists of preferred or recommended prescription drugs they use. Often these lists are used to encourage doctors to prescribe generic forms of medications that are similar but less expensive than brand-name drugs. Since plans very widely when it comes to formularies, you should find out if the drugs you need are on the plan’s list by asking the member services department of your plan.
  • Plans may say their formulary list is used to control the quality of members’ care, but be cautious. According to critics, some formularies restrict the use of better but more expensive drugs for cheaper ones, or certain products will be included simply because the plan gets rebates from a particular manufacturer. If you think these factors are preventing you from getting quality care you should appeal through your plan.
  • Federal law requires managed care plans to pay for emergency care whenever or wherever you need it. Sometimes there is a question as to what is truly an emergency but it’s safe to say that if you feel your health is in serious danger, you should go to the closest emergency room immediately. If this happens, have someone acting on your behalf notify the plan as soon as possible. This can help insure your right to coverage later.
  • If you have a serious illness such as cancer or heart disease, or a chronic condition such as arthritis or high blood pressure you should find out how your plan treats people with your condition. Some plans have “practice guidelines” or “disease management” programs that your doctor is required to follow. If you’ve been recently diagnosed, do some library research on your own to find out more about your illness.
  • Even though many plans say they cover nursing home, home health care and rehabilitation, these are the services most often denied, so be prepared to fight for this care if your plan says no. For nursing home care you can contact your state’s long term care ombudsman through the Eldercare Locator, which will refer you to your local Agency on Aging. Call 1-800-677-1116.
  • Above all, do not hesitate to appeal rulings that you do not agree with. It is usually troublesome and time consuming but it often results in the plan changing their decision in your favor. Many plans deny care until somebody raises a complaint. Get all notifications of termination or denial of care in writing with both financial and medical reasons for the denial included. Enlist the support of your doctor, if your doctor won’t help, get a second opinion.

    Source: AARP, www.aarp.org

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