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Going to War with Your HMO

Copyright (C) 1997 by Steve Litt. -- Legal

Please Note:

Note: The course of action below is confrontational, and could backfire in certain situations. Use it at your own risk. This website, its owners and contributors, are not responsible for the outcome.
This course of action must be used only in situations where serious injury is likely without proper treatment, and where the HMO is reluctant to give reasonable treatment in a timely basis. Furthermore, use this course of action only when you are committed to fighting, tooth and nail, to obtain proper treatment. This commitment includes risk of lawsuit and harassment, threats, attempts to completely cut off medical care, and who knows what else. Plan to take significant time off work for research, and possibly to go to court. HMO executives can be as vindictive as anyone else. Note also that a law called ERISA can limit your options in suing or persuing criminal action against an incalcitrant HMO.
Do not use this course of action "for the principle of the thing", to obtain "the treatment I deserve", to "teach them a lesson", or to "make a point". Use this course of action only to save yourself or a member of your family from death or serious injury caused by an HMO's penny pinching and foot dragging.

That being said, I think the below described course of action is usually safer than taking a passive stance when an HMO blatantly puts profits above patient safety.

Start by using the Internet and your public library to find out the usual and customary treatment for your condition. If a specialist is usual and customary, don't let a general practitioner manage your case. If an expensive antibiotic is usual and customary, don't let them treat you with an inferior one. Here's what you do:

The minute they put you or your family in jeopard by treating you "on the cheap", start by consulting Black's Law Dictionary. Look up malpractice. That will contain a reference to negligence. Look that up. It will contain a reference to negligent homicide. If your condition could become life threatening (to yourself, a family member, or even an unborn baby), look that up. You'll see a reference to second degree murder. Be sure to actually look these things up to see how they would apply to your specific case. Then look up the statutes and the case law. Have your librarian help you. Of course, it would be extremely hard to make a case for something like murder, but now, as you go into negotiations, you know their downside risk. Please note, however, that a law called ERISA can limit your options in suing or persuing criminal action against an incalcitrant HMO.

Next, write THE LETTER:

Dear __Person most instrumental in the decision__

cc ___Other personel who could conceivably be civilly or criminally liable, including top managment__

___First sentence or two describes the patient, the condition and the situation___. Although usual and customary procedure for ___name the condition___ is __name the course of treatment___, your organization has restricted treatment to __their suggested treatment__.

Our position is that you should follow usual and customary procedure and ____describe correct treatment here____. If your organization chooses to take the unusual and non-customary step of ____describe the treatment they're giving or proposing___, you're taking responsibility for our case, and we will hold your organization fully responsible, legally and financially, for the outcome. Taking chances with ___describe the condition___ is not cost effective.

Our intent is to reach an agreement, to be given a written copy of that agreement, and to have access to ___describe correct treatment here___ according to that agreement. We have been trying unsuccessfully to resolve this matter with ___name the person you've been talking with___ for the last ____ weeks. We would therefore view an answer of "we'll get back to you later with the answer" as a further stall tactic and act accordingly.

We are informed health care consumers. Please don't take us lightly. We're very serious about the situation and ready to do what's necessary to get reasonable and prudent medical care. We look forward to quickly resolving this issue with you.

Very truly yours

You may need to augment the letter by letting the "little people" know the consequences. I once told an HMO office manager I'd hold her responsible and press for a negligent homicide conviction if a patient I loved died. She threw me out of her office, but it's funny, a week later the HMO capitulated. You might want to make sure the people in "utilization review" know they're more than clerks - you'll hold them legally and criminally responsible. As far as the bigwig HMO directors, you might remind them of Fox vs. HealthNet, and how it cost Healthnet $89 million. Here are some Fox v Healthnet links:

Copyright (C)1997 by Steve Litt. -- Legal

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