From Exam Room to Courtroom Get Necessary Tests & Treatments
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HMO HARDBALL is a deadly game that HMOs and their doctors play with patients to wrongly deny medical tests and treatments. The game relies on secret, ruthless rules and dirty tricks. HMOs and their doctors play HMO HARDBALL to insure the survival of the HMO business that produces and protects their money and power.

HMOs and their doctors deny that the game exists, but patients are learning the truth—the hard way. Patients are angry and fearful, because they don't know how to win the game. Losing the game results in needless disease, disability, and death.


Why is HMO HARDBALL unfair?

  • HMOs make unfair rules and use dirty tricks to control the game.
  • Patients don't understand how the game works
  • Patients don't have a proven system to win the game.


Why do HMOs and their doctors win the HARDBALL Game?

HMOs and their doctors unfairly control medical services provided to patients, because HMOs have the legal and financial power to control how doctors decide...

  • What healthcare services are "medically necessary."
  • Where "medically necessary" healthcare services are provided.
  • When healthcare services are "medically necessary."
  • Who provides "medically necessary" healthcare services.
  • How "medically necessary" healthcare services are provided.
  • How long "medically necessary" healthcare services are provided.


How do HMOs and their doctors deny patients medically necessary healthcare?

HMO insurance policies (contracts) are written to justify denial of healthcare. For example, my family's HMO defines healthcare to be "medically necessary,"

"...only if a Plan Physician [emphasis supplied] determines that its omission would adversely affect your health and that it is a medically appropriate course of treatment for you."

In plain English, the HMO will not pay for any healthcare service (benefit) listed in the insurance policy unless...

...the HMO's doctor decides that the patient's health would be adversely affected and that the services are medically appropriate. Wouldn't patients prefer that their own doctors, not HMO doctors, make medical decisions?

The HMO does not state that an HMO doctor's decisions are final and do not require review and approval by other doctors and HMO bureaucrats. Don't HMOs promise not to practice medicine or "second guess" your doctor?

HMOs know that controlling doctors' medical decision-making is the key to controlling medical costs. HMOs identify and counsel doctors whose costs for patients are deemed excessive. The HMO secret police force is watching. HMOs know that, when they have doctors by their paychecks, their hearts and minds will follow.

Contracts control healthcare in all managed care plans, not just HMOs. HMO mouthpiece, William Gradison, inventor of "Harry and Louise," revealed the reality of how managed care really works. In response to questions about denial of care to flesh-and-blood patients, what did Mr. Gradison tell the CNN correspondent? "Show me the contract!"


How does this work in my family's HMO?

  • My wife's neurologist decided that her health would be adversely affected if she didn't receive expert treatment from a non-Plan physical therapist.
  • The doctor wrote a detailed justification for the medical necessity of the referral.
  • The neurologist's referral was disapproved by our Health Plan's Assistant Area Medical Director, a pediatrician, who stated that her treatment must be provided by a Plan therapist.
  • When my wife disputed his decision, the pediatrician sent her the contract, warning that her therapy might not be a covered benefit at all.
  • My wife appealed the denial and requested a copy of the referral document. The pediatrician replied that the document was missing and that it wasn't important.


Medicare Hardball

Medicare pays HMOs a fixed amount of money to provide healthcare for each recipient they enroll. HMOs and their doctors play hardball with Medicare patients, using the same secret, ruthless rules and dirty tricks designed to deny healthcare to all patients.

My wife's mother asked me to explain the Medicare HMO sales brochure. As she handed it to me, she exclaimed, "Look at all the benefits you get!" After reading the fine print, I replied that patients aren't guaranteed anything.

The brochure stated that "enrollees" are "eligible" to receive benefits, only if an HMO doctor approves them. Even then, the HMO and its doctors may deny benefits on such hairsplitting technicalities that treatments are "experimental" or "investigative." I also pointed out examples of HMOs withdrawing certain benefits entirely once they had sucked elderly patients into their system.

I telephoned my HMO's Member Services Department (customer service) and requested detailed information on Medicare complaints and appeals. The representative I spoke with did not provide any written information on the HMO's Medicare complaint and appeals process. We decided that his nonresponsiveness to the needs of prospective senior patients was a preview of coming HMO attractions. No HMO Wonderland for Mom!


Applying Patient Pressure to Win the HMO HARDBALL Game

Patients can beat the HMO HARDBALL pros by using the Patient Pressure System. This system empowers patients to make HMOs and their doctors feel pressure, when they make dishonest decisions about the medical necessity of tests and treatments. The application of systematic pressure is the key to winning the HMO HARDBALL game.

The Patient Pressure System replaces patient frustration and anger with strategic thinking, control, and constructive problem-solving. Patients learn to correctly apply pressure to persuade HMOs and their doctors to do what's right voluntarily. If persuasion fails, patients learn to apply pressure with appeals to regulatory agencies that can order HMOs and their doctors to do what's right.


What Is the Patient Pressure System?

The Patient Pressure System is a proven, 3-step patient self-protection system. It is an easy-to-use method for patients to enforce their rights, when healthcare is wrongly denied. Patients learn to use their power, as necessary, to pressure doctors and HMOs to do what's right. The Patient Pressure System provides proactive patients with a systematic method to fight wrongful denial of medical services by HMOs and their doctors.

The Patient Pressure System starts by asking for the doctor's cooperation. Confrontation only occurs when patients are wrongfully denied necessary healthcare and information that governs healthcare decision-making. Patients gain self-esteem associated with being treated as "somebody," rather than "nobody" by HMOs and their doctors, when they learn to protect themselves.

The President's Commission on Consumer Protection and Quality in Health Care adopted a Consumer Bill of Rights and Responsibilities, stating that "individual involvement by patients in their care increases the likelihood of achieving the best outcomes." HMOs and their doctors do not welcome individual patient involvement that results in power-sharing. Power-sharing makes wrongful denial of healthcare difficult.

The Commission did not recommend how the right to individual patient involvement should be enforced. The Patient Pressure System adds the missing link to the Commission's report. Starting in the exam room, it provides a systematic method for patients to persuade their doctors to do what's right. If their doctors intentionally do what's wrong, patients also have a systematic method to submit convincing appeals to outside authorities.


Why Does the Patient Pressure System Work in All Managed Care Health Plans?

The Patient Pressure System can be used by patients who are members of any managed care organization, not just HMOs. All managed care organizations have contracts with patients and doctors that dictate how "medical necessity" decisions are made and reimbursed. The Patient Pressure System focuses on how those contracts influence a doctor's decisions and on how patients can pressure doctors and managed care organizations to do what's right.

Patients must demand that managed care organizations show them the contract up-front, because all decisions will be based upon the fine print.

What Are the Patient Pressure System's Three Steps?

Step 1: The Advance Report Card

HMOs require that patients, doctors, medical groups and physician management companies enter into written legal contracts concerning provision of health services, payment for health services, and dispute resolution concerning health services. Patients are not given the opportunity to include their own expectations in these contracts. HMOs force patients to "take-it-or-leave-it." As a result, all HMO contracts are unfair. Patients don't have authority. They don't make the rules. It's difficult to successfully appeal wrongful HMO decisions without help.

The Advance Report Card provides a systematic method to help patients ask HMO doctors to explain how the patient's contract with the HMO affects medical decision-making. Most important, the Advance Report Card asks HMO doctors how their own contracts with HMOs, physician management companies and medical groups affect patient care decisions.

The Advance Report Card shines light on doctor-patient-HMO relationships. Instead of vague reassurances of "medically necessary quality healthcare," doctors are asked to reveal the nitty-gritty details of how HMOs, physician management companies and medical groups really advance!

HMO doctors are asked to respond to questions concerning patient healthcare decisions and the impact of HMO, physician management company, and medical group business practices upon patient healthcare decisions. Patients have turned the pressure cooker to the low setting. Their chances of receiving necessary healthcare are increased.

Advance Report Card forms for readers are included at the end of this book. They are easy to complete by "filling-in-the-blanks" and with "yes or no" answers to questions.

Step 2: The Fact Attack

The way that HMOs, medical groups and physician management companies do business insures that HMO doctors and patients play hardball. They will fight over what "medically necessary" healthcare means in terms of diagnostic and treatment decisions. Ideally, these fights should be resolved according to who has the best facts and analysis and how they relate to maintaining and promoting the patient's health.

The Fact Attack provides a systematic method to help patients identify and analyze relevant facts, when disputes arise with their HMO doctors over the best medical decision-making. The Fact Attack attacks the doctor's facts, not the doctor.

The objective is to resolve disputes cooperatively between patient and doctor without formal written appeals to the HMO or regulatory authorities. Fact Attacks are intended to change the HMO doctor's initial decision to wrongfully deny tests and treatments.

HMOs and their doctors can run from the facts, but they can't hide. Fact Attacks turn the pressure cooker to the medium setting. Patients' chances of receiving necessary healthcare increase.

Fact Attack forms for readers are included at the end of this book. They are easy to complete by "filling-in-the-blanks" and with "yes or no" answers to questions.

Step 3: The Insecurity Blanket

Insecurity Blankets are systematic formal appeals regarding wrongful delay and denial of medically necessary healthcare.

HMOs, physician management companies, and medical groups pressure their doctors to disregard facts, logic and simple human decency in their medical decision-making. They punish doctors, if diagnosing and treating patients decreases profit beyond business plan forecasts.

HMOs pressure doctors to play hardball with their patients. If it's "them" or "you," the HMO doctors won't help you. Their income and employment are at stake. HMO pressure forces doctors to fight, not help, their patients.

HMOs and their doctors cling tightly to security blankets made of money and power to protect themselves from patients who demand medically necessary healthcare that has been wrongfully denied. To successfully appeal dishonest decisions, patients must take away HMO doctors' security blankets.

Patients must cause insecurity, when HMO doctors intentionally to do what's wrong. Insecurity Blankets empower patients to cause regulatory authorities to overrule wrongful healthcare decisions and to punish HMOs and their doctors.

Insecurity Blankets help patients in three ways:

1. Patient appeals systematically and persuasively pressure HMOs, physician management companies, medical groups and their doctors to follow health plans, not business plans. Patient complaints become public. Publicity causes insecurity.

2. Patient appeals logically persuade and pressure regulatory authorities to overrule HMOs and their doctors based on facts and analysis. HMOs and their doctors may not only be ordered to provide healthcare, but also may be punished for their bad intentions. The threat of punishment causes insecurity.

3. Patient appeals serve as a paper trail to document what has happened, if down the road, patients must consult lawyers to pressure HMOs to do the right thing. Patient lawyers cause insecurity.

Patient appeals turn the pressure cooker to the high setting. Patients' chances of receiving necessary healthcare are increased. Insecurity Blanket appeal forms for readers are included at the end of the book that are easy to prepare by "filling-in-the-blanks" or with "yes or no" answers to questions. Two standardized appeal forms at the end of the book prepare and direct patient appeals to HMOs and state regulatory agencies.

Pay Attention to the Titles

The titles of all HMO rules and dirty tricks were carefully chosen to put pressure on your HMO and its doctors when they do what's wrong. Public shame and ridicule serve a vital purpose in playing HMO HARDBALL. Never forget that HMOs and their doctors don't hesitate to unfairly blame patients for everything. It is in your interest to refer to HMO HARDBALL rules and dirty tricks by their titles in all your HMO communications. Your HMO and its doctors will know that you're aware of "the reality of how this stuff works." Your healthcare needs will be taken much more seriously than those of patients who suffer in silence, beg, or feel they must apologize for protecting themselves.

What Does the Patient Pressure System Do for Patients?

  • Patients have their own easy-to-use, self-protection system to enforce their rights.
  • Patient anger and frustration are replaced with strategic thinking, control, and constructive problem solving.
  • Patient responsibility = HMO accountability.

Created and produced by Robert and Jacquelyn Finney, CounterPoint Communications.

Website consultant Ray Koch, Groundswell Productions

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