Patients get help on HMO disputes

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Sacramento Bee

Consumers puzzled by the increasingly dense thicket of regulations surrounding HMOs now have a new place to turn for help resolving health care disputes.

The state Tuesday released a patients’ rights guide that explains how to file formal complaints against HMOs and request second opinions when care is denied.

In recent years, California lawmakers passed sweeping health care reforms allowing consumers wide latitude to challenge medical decisions and sue in court if they aren’t satisfied by binding arbitration required by most health plans.

But word of the reforms has been slow to reach the state’s 21 million HMO members.

“People don’t know their rights, and they have no clue where to go when they have a problem,” said Barbara Moore, a registered nurse at Mercy General Hospital in Sacramento.

Moore, a breast cancer survivor, said she didn’t know she could ask the state for an independent medical review until her HMO refused to pay for repair of torn scar tissue that developed after breast reconstruction surgery.

After exhausting all appeal options with her medical group, Golden State Select, and her HMO, Western Health Advantage, Moore took her case to the state Department of Managed Health Care, which arranged for a panel of physicians to review the case. The case is still pending.

Since January, physician panels have heard 144 cases. The panels overturned HMO decisions in 36 of those reviews, according to the department.

Each month, the department gets about 15,000 calls for help with HMO-related problems.

In addition to options for resolution of care disputes, the new guide details patients’ rights to insurance when they have a pre-existing medical condition or emergency treatment when they lack coverage.

“It’s a tool kit and compass so patients can have some leverage against HMOs and some direction when they have a problem,” said Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights, which, along with the Wellness Foundation, helped the state produce the guide.

For the most part, HMOs support recent state efforts to help consumers navigate the health care system, said Bobby Pena of the California Association of Health Plans.

“It’s a good check-and-balance system, and there’s a level of comfort for consumers in knowing they can have an unbiased, fair decision made when they have a complaint,” Pena said.

Still, Pena objected to the slant of the new guide, which he said overemphasizes patients’ right to sue HMOs.

“The vast majority of problems are resolved internally when people first call their HMO,” Pena said. “Very few cases go to arbitration and even fewer are appealed to the state.”

The guide is available online at

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