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Bob Rosenblatt

Los Angeles Times

The New Year brings more weapons to the arsenal of consumers as they fight to make their way successfully through the increasingly complicated world of health insurance.

Medicine gets better every year in its ability to help people overcome disease. The real challenge is making the system work for you, delivering the care you need with a minimum of delay and obstruction.

Consumers will get vital help in 2001 in areas ranging from Medicare coverage, to HMO appeals, to insurance to defray the costs of delivering a baby.

Here is a compendium of the ways you can make the most of health care coverage this year.

When Your HMO Says No

A new California law gives consumers the right to an independent appeal when an HMO says that a treatment, procedure or referral to a specialist is not medically necessary. First, you appeal within the HMO, or health maintenance organization, itself. If your appeal is denied, you have the right to an outside review by independent doctors who do not work for the health plan.

The new California Patients Guide, prepared by a consumer advocacy group with help from doctors and nurses, is a useful document for anyone trying to make sense of the complex health care system. It discusses topics such as treatment in the emergency room, getting a second opinion, maintaining medical privacy and taking legal action. It offers these examples:

“You can use the independent review process, for example, when your doctor is recommending a hysterectomy for treatment of recurrent cervical cancer, but the HMO will only approve cervical cryosurgery. Similarly, when the doctor recommends proton beam radiation for treatment of prostate cancer, but the HMO only approves surgery, you can also use the independent review process.”

The California Department of Managed Health Care, the state agency that regulates HMOs, will handle the appeals process.

The guide was prepared by the Foundation for Taxpayer and Consumer Rights, a Santa Monica lobbying group active in consumer health access issues. It was developed with funding from the California Wellness Foundation, a nonprofit health care philanthropy based in Woodland Hills. The state Department of Consumer Affairs, as well as medical organizations, also worked on the guide. It has specific citations to state laws to help consumers know the law when they appeal HMO decisions and rulings.

The Web site location for the document is http://www.calpatientguide.org. Printed copies are available from the foundation at: FTCR, 1750 Ocean Park Blvd., Suite 200, Santa Monica, CA 90405. Copies can be requested by e-mail at: [email protected]. The phone is (310) 392-0522, Ext. 308. A Spanish-language version will be available in March.

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