Surviving the HMO

A Step-by-Step Guide

       Vikram Khanna's book "Managed Care Made Easy: Survival in the HMO Era" (People's Medical Society, $14.95) offers a step-by-step guide through a health plan's appeal process, condensed here.

"At the first sign of a problem, for example, your primary-care doctor or plan refuses to refer you to a specialist when you believe you need one, start keeping notes.
"If you disagree with your doctor about a clinical issue, ask him to clearly document in your medical record that you and he disagree.
"Ask your physician for a copy of your medical record, which should include lab results, reports from specialists and other information that may help you document the validity of your complaint.
"Mail your letter to the plan official identified in your enrollment materials as the person who handles consumer complaints. Send the letter by certified or registered mail.
"Within seven to 10 days, contact the plan to find out who is handling your complaint and ask how quickly you can expect the plan to act.
"Follow up with plan officials frequently to assess the status of your complaint.
"If appropriate to your complaint, ask your primary care physician or specialist to help.
"When your physician submits a letter supporting your grievance or appeal, make sure it is accompanied by copies of any medical studies or other expert opinions (such as letters from specialists) that help document why a disputed test or treatment is appropriate.
"When your plan completes its review, insist that it provide you with a written decision.

 
C. Grannan

HMOs Return