Mr. H Appealing HMO Decision

¶ … Mr. H

Appealing HMO Decision

What procedural remedies does the patient likely have under private insurance and under Medicare or Medicaid? Are they adequate?

A recipient of Medicaid can apply for a Medicaid Fair Hearing to "appeal an adverse decision including a denial of a request for services" deemed medically necessary and a Medicaid-covered service (Handling Medicaid Denial, 2010, Families USA). Under California, a medically necessary service is deemed one that is "reasonable and necessary to protect life, prevent significant illness or significant disability or alleviate severe pain" (Handling Medicaid Denial, 2010, Families USA). Given that Mr. H wished to avoid an amputation, had he been a Medicaid recipient he would have had clear redress in California, given his situation. Although it was subsequently approved for Mr. H to receive vein by-pass surgery in lieu of amputation, Mr. H was then merely referred back to his current medical group, which did not contain any physicians who had ever performed that type of surgery. This hardly seems like a satisfactory solution for Mr. H. The rationale given for this, that Mr. H had already had enough requests approved, does not seem reasonable or sufficient to deny the patient adequately experienced medical treatment.

Thus had Mr. H received Medicaid insurance, the form of government-provided health insurance provided to individuals living below a particular income threshold, he would have had some redress in the state of California. However, this might not have been true in another state, as there is no definition of medically necessary treatment under federal laws for Medicaid (Handling Medicaid Denial, 2010, Families USA). Under Medicare, the government-provided health insurance for the elderly, government guidelines state that individuals can appeal a claim if they are "entitled to Medicare and have not received the item or service…within 6 months of the date of the treating physician's written statement that you need to get that item or service" (Appeals of local coverage determinations, 2010, Medicare). Had Mr. H been a recipient of Medicare, he would thus have had to have formally appealed the denial in a timely fashion, citing the necessity of the procedure.

The problem regarding Mr. H's claim with an HMO plan is the need for individuals to remain within the network to receive care. Initially, Mr. H was denied coverage because he did not get a referral from his primary physician to see a specialist. The original treatment to which Mr. H's primary care physician was subjecting Mr. H was 1. not effective and 2. The physician suggested a radical amputation for his condition while the second opinion Mr. H sought suggested a much less radical procedure which would allow Mr. H to retain his mobility. It could be logically argued that had Mr. H not gone 'out of network' he would have suffered substantial medical harm. Furthermore, while the HMO cited as a reason for denial of claim a provision in the plan documents that prevents referrals outside the plan's network when the network's physicians have the capability to perform the required procedure, Mr. H seems to have legitimate questions about his in-network physician's competence to perform the procedure.