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
"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
"When your plan completes its review, insist that it provide you with a written