Navigating the HMO seas

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New guidebook a life raft for patients

The San Francisco Chronicle

Her long battle against the state’s biggest health maintenance organization has made Terry Preston an expert in tenacity.

“I learned the hard way that HMOs and the health care industry rely on the waiting game,” said Preston, the daughter of a woman whose death prompted a $1 million fine last year against Kaiser Permanente.

Preston, of Hayward, said she would have saved countless hours in her case against the HMO giant had a new patient’s-rights guide just released by the state been available when she first waged her battle.

The free 80-page guide, which is available through a variety of sources including online, is designed to help people navigate their way through the complex maze of health care rights and regulations.

A number of sweeping health care reforms went into effect Jan. 1, but consumer advocates say most people are unaware of those new rights. For example, patients have a right to an independent medical review if their request for treatment is denied by their insurer. They also have the right to sue their HMO.

“This is basically an owner’s manual for the new patient’s bill of rights in California,” said Jamie Court, executive director for the Foundation for Taxpayer and Consumer Rights, one of the main groups behind the guide.

The guide covers a variety of patient issues in a question-and-answer format — everything from confidentiality concerns to HMO grievances — and cites the codes and laws that support each right. Also included is a glossary of terms and sample letters a patient might need to write.

Preston, who wrote the forward for the guide, is still entrenched in her battle against Kaiser because the HMO is appealing the $1 million award, the largest fine involving a single patient against a HMO.

Her 74-year-old mother, Margaret Utterback, died Jan. 28, 1996, from a ruptured abdominal blood vessel, or aneurysm, at the Hayward hospital. Utterback, who reportedly had spent more than eight hours trying to see her doctor, died minutes after being admitted.

The $1 million fine accounts for the bulk of the $1.5 million in fines against HMOs that has been assessed since the inception of the state Department of Managed Health Care last year. The other major penalty was the $250,000 fine levied against PacifiCare Health Systems Inc. in March for late payments to doctors and hospitals.

Steven Fisher, a spokesman for the Department of Managed Health Care, said the department fields about 15,000 calls per month through its call center. About half of those calls are from people wanting to know how to contact their health plan.

Since January, when patients first had the opportunity for an independent review, 144 people have taken advantage of that right. Of the cases resolved, about a third have been decided in the patient’s favor. The decisions are binding.

Fisher said he does not think those are poor odds for patients. He said the department has been able to handle the bulk of patient concerns in a timely fashion so the cases that reach the independent review stage tend to be more complex.

The guide, “The California Patient’s Guide: Your Health Care Rights and Remedies,” was produced by several groups. The guide was funded primarily by a grant from the California Wellness Foundation. The state Department of Managed Health Care will be translating the guide into Spanish and Chinese.

The California Medical Association will make some of the 40,000 printed guides available in the offices of its member doctors. The guide is available on the Internet at

People can also receive a copy by calling (800) 952-5210 or (888) 466-2219.

Consumer Watchdog
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