posted on December 26, 2000 09:29:09 AM new
bearmom's mention of HMO's brings up an interesting topic which may have been discussed previously. however, i know that there are many "horror stories" involving HMO's and an opportunity to vent on this topic is always welcome. from not being able to get appointments, to having to wait for a referral to see the doctor you need to see, to getting billed for services that should have been covered,to needing medicines that are not covered,to not being able to get serious conditions covered etc. what are some of your HMO horror stories?
posted on December 26, 2000 10:07:06 AM new
My 5 year old daughter was in the hospital for 4 days with pnuemonia a week and a half ago. She was admitted right before midnight on a Friday. My insurance requires that if you are admitted to the hospital in an emergency that you have 24 hours to get the stay pre-certified or you will be fined $1000. My husband and I both called all day Saturday and Sunday and never got a live person. Called Monday morning and they informed us we were being fined for not pre-certifying her stay. I am sure that by the end of the day they wish they had never heard of me. To make a long story short, no fine.
posted on December 26, 2000 10:11:24 AM new
My husband went for his yearly checkup last year-total of 596 dollars. (He's diabetic, so it's a pretty comprehensive checkup). we had just started with a new HMO through our school system, and had not received anything about what was covered, what deductibles were, etc. So he just paid the entire bill, and I sent it in to the insurance company for reimbursement.
The HMO has a deal with the doctors they use to discount the costs. The discount on this visit was 192 dollars, so we actually did not owe but 404 dollars. The doctor's bookkeeper refused to refund the overpayment, the HMO told us 'tough luck'. It took 6 months, and a letter or two to the state insurance board to get our money back. The HMO's stance was that we should have known better than to pay our bill!
posted on December 26, 2000 10:14:28 AM new
hcross, we had the exact same thing happen. I was admitted to a local hospital on Friday morning, they called the HMO. Then they decided to transfer me to a Dallas hospital later that day. By the time I was transferred, the offices were closed, so they called the HMO Monday morning.
Same deal, reduced coverage. It took several years to get that taken care of!
posted on December 26, 2000 10:18:45 AM new
Hcross: good work, too many people just pay up and don't realize that if you grip enough to the right people you can usually get a break. If you can prove your in the right stick to your guns.
Here in Houston I use the "Marvin Zindler" threat as my last resort. He is one of our local newcasters who has made a name for himself going after crooked business men. No company wants to see themselves on the nightly news when they know they have given you a bum deal.
It has never failed me yet.
posted on December 26, 2000 10:48:43 AM new
hcross- when you say "fined" $1000, do you mean that you would have to pay a $1000 deductible for using the facility without pre-certification? p.s.-how is your daughter doing?
posted on December 26, 2000 11:27:47 AM new
We had met our family deductible for the year, I just got the bill and it was $6,000, part of the bill was paid at 80% and other parts of it were paid at 100% because we met our out of pocket. Our part of the bill is actually less than $1000. The $1000 "fine" is not part of the deductible. If they had gone ahead with it, the first $1000 of the bill would have been our punishment for not being able to get through to them on the week-end. The remaining $5000 would have then been paid normally.
I used to be a Medical Claims Examiner for Mutual of Omaha. What insurance companies count on is that most people will get tired of fighting it, and they do let it go in most cases.
My husband is on 24 hour call and took several days off so he could take the night shift at the hospital with her. His work knew immeadiately what was going on. When they tried to "fine" me, I started with his Supervisor and went on up from there. We had also documented the times we tried to call, the Doctor and admissions people also tried to get through.
Since we live in a smaller town we really don't have an HMO, if we were with the one of the bigger districts we would be. We can see almost any Doctor that we want and get most any treatments that we need.
Stusi: Thanks for asking, she is doing better, she has severe Asthma and has such a bad Asthma attack that pnuemonia set in. We had to buy a Nebulizer so we could do breathing treatments at home, she is now a happy little camper since she is mostly off that. Nothing worse than seeing such a small child in the hospital with oxygen, iv's and all that good stuff, when we got her to the ER her blood oxygen was only 79 and stayed that way for 3 days. Heather
posted on December 26, 2000 01:03:27 PM new
Several years ago my shoulder started bothering me. The first symptom was I was lifting my arm and something caught and I lost all strength. Now that is not normal! My HMO doctor over the next 3 years just kept giving me pills and sheets with exercises on them. She never would send me to a specialist.
We finally moved and I changed doctors. My new doctor was shocked that it had been going on for 3 years now! She sent me to the specialist right away. Now I'm no doctor, but I could tell after what the specialist told me he thought is was that had not listened to a word I said. Not to mention he moved my arm every which way and had me in tears by the time I left. This was in October, which was our open enrollment period. I had already made up my mind to switch plans and that visit clinched it.
Thank goodness we could switch plans. So I switched and come the first of Jan. I called my old orthopaedist and made an appointment. His exam was very gentle because he listened and knew I was in a lot of pain. The only thing left was cortisone shots, which if anything made it worse. So I had surgery that summer on my shoulder.
It turned out I had a bone spur on the joint. It had been there so long it ripped my bursa to shreds, talk about extreme bursitis! There was no saving it, so they removed it along with the spur.
It's too bad I had not documented things better, otherwise I would have gone after the HMO and my old doctor. Oh, and the funny part about it is right about when I had surgery, the clinic I was going through on the HMO went out of business. Even though it cost me more out of pocket on the new plan, I was glad I switched. Never again will I choose and HMO.
edited to add a 'd' and fix my bold.
~~MouseSlayer is not a cat =^..^= ~~
[ edited by mouseslayer on Dec 26, 2000 01:06 PM ]
posted on December 26, 2000 01:46:40 PM new
hart-was it the same doctor that prescribed the wrong meds, ignored allergies and missed the tumor? did you consider malpractice? mouse- do you think that the caliber of doctors participating in certain HMO's is different or is it that they must treat larger volumes of patients to make the same living they made before the advent of HMO's?
posted on December 26, 2000 02:12:16 PM new
heather...get well wishes to your daughter. Must have been awful for you guys seeing her so sick.
I've actually had better luck with my HMO clinic than I did out here with an indepedent doctor. While it's very rare that I have to see a physician, at least I know the doctor I see will listen to me and not just write out a prescription to cover the symptoms. I think you have to find the good doctors within the groups themselves.
And I'm switching my son from a Pediatric group to our Clinic. It seems any immediate care my son usually needs comes on a weekend when the Pediatric office is closed. When that happens, we have to use the hospital emergency room and they always give us a hard time about it. At lease my clinic has an Urgent Care center opened 7 days so we can use that without the hassle.
posted on December 26, 2000 02:21:21 PM new
So... why would anyone choose an HMO in the first place in light of all the HMO horror stories?
Is there no choice offered, or is other insurance prohibitively expensive? I know that PPO costs are slightly more up front, but it's well worth it if anything goes wrong.
posted on December 26, 2000 05:20:03 PM new
This is good....
In the beginning God created the heavens and the Earth. And the Earth was without form, and void, and darkness was upon the face of the deep. And Satan said, "It doesn't get any better than this."
And God said, "Let there be light," and there was light. And God said, "Let the earth bring forth grass, the herb yielding seed, and the fruit tree yielding fruit," and God saw that it was good. And Satan said, "There goes the neighborhood."
And God said, "Let us make Man in our image, after our likeness, and let him have dominion over the fish of the sea, and over the fowl of the air and over the cattle, and over all the Earth, and over every living thing that creepeth upon the Earth." And so God created Man in his own image; male and female he created them. And God looked upon Man and Woman and saw that they were lean and fit. And Satan said, "I know how I can get back in this game."
And God populated the earth with broccoli and cauliflower and spinach, green and yellow vegetables of all kinds, so Man and Woman would live long and healthy lives. And Satan created McDonald's. And McDonald's brought forth the 99-cent double cheeseburger. And Satan said to Man, "You want fries with that?" And Man said, "Supersize them." And Man gained 5 pounds.
And God created the healthful yogurt, that woman might keep her figure that man found so fair. And Satan brought forth chocolate. And Woman gained 5 pounds.
And God said, "Try my crispy fresh salad." And Satan brought forth Ben and Jerry's. And Woman gained 10 pounds.
And God said, "I have sent thee heart-healthy vegetables and olive oil with which to cook them." And Satan brought forth chicken-fried steak so big it needed its own platter. And Man gained 10 pounds and his bad cholesterol went through the roof.
And God brought forth running shoes and Man resolved to lose those extra pounds. And Satan brought forth cable TV with remote control so Man would not have to toil to change channels between ESPN and ESPN2. And Man gained another 20 pounds.
And God said, "You're running up the score, Devil." And God brought forth the potato, a vegetable naturally low in fat and brimming with nutrition. And Satan peeled off the healthful skin and sliced the starchy center into chips and deep-fat fried them. And he created sour cream dip also. And Man clutched his remote control and ate the potato chips swaddled in cholesterol. And Satan saw and said, "It is good." And Man went into cardiac arrest.
And God sighed and created quadruple bypass surgery. And Satan created HMO's.
posted on December 26, 2000 06:29:09 PM new
We live in the boonies. Husband's employer had insurance that we were paying $46 per week for coverage, plus all the lovely co-payments and a percentage of hospitalizations, etc. ACK. Best part of it was that this insurance company had a grudge against medications that started with the letter Z. I had been on Zoloft for years - 50 mg a day - and that co wouldn't cover 50 mg Zoloft...but they'd pay for 100 mg Zoloft! LOL! Dr rewrote the Rx, and I got two months worth at a time, cutting them in half. There is an antibiotic, too..the super one, that you only take for five days instead of ten (can't think of the name, but it starts with Z!) - nope. They wouldn't pay for it.
While my mom was still alive - the HMO she was part of cost her several months of her life because the nuerologist they said she had to go to demanded that she have an MRI. She was deaf and what they termed a "hysterical patient", and she freaked out when they tried to do the test. I asked the dr to please try a cat scan - she refused. I fought with all of them, for six weeks, until I got them to send her to another neurologist. That one did a cat scan, and there was a big assed tumor clear as day on her brain. That first doctor, in her holier than thou wisdom, caused a cancerous tumor to go without treatment for six weeks - growing rapidly the whole time. Had it been detected sooner, the surgeons would have had a much better chance of removing it and buying her more time, but by the time it was detected, it was well wound into the brain, and they wouldn't touch it.
I think of that old bat doctor now and then. And hope there is such a thing as karma.
posted on December 26, 2000 06:41:27 PM new
At my place of employment they have a choice of 2 HMO's, 1 PPO and 1 80/20 plan. At the time I signed up for the HMO I was generaly healthy and it had no out of pocket cost except prescriptions. But what it saved me as far as money cost me dearly in pain and physical trauma. A hard lesson to learn for someone who was basically a kid at the time and now it will cost me more when I get older and have arthritis.
stusi, I think it's a combination of they have to treat (using the term lightly) so many and the pressure of the HMO to not send patients to a specialist. Everytime I brought the issue of my shoulder up to my doctor, she would roll her eyes like, "Here we go again about this." She acted as though it was in my head. Or it could be she just forgot between visits and never read my chart. Then again, the specialist I finally was sent to was an a*s so I'm not sure what good it would have done any sooner.
I finally went with the PPO plan and have been very happy with it. And because my employer is the largest private employer in my state, there is no shortage of doctors on the plan. It's very easy to recommend a doctor and have them put on it. Oh, and not only did my old HMO clinic go belly up, but that particular HMO plan was frozen the following year. Meaning no one could sign up for that plan because they were rated poorly by the patients on that plan. My employer takes our satisfaction seriously.
posted on December 26, 2000 07:38:23 PM new
maddienicks-what happened to your mom is very sad. things like that happen all too often with the HMO's. there seems to be no rhyme or reason to the prescription formularies. although you couldn't get zithromax, did they come up with a substitute? many people get double strength pills and cut them in half but to cover one strength and not the other is inexplicable.
posted on December 26, 2000 07:48:02 PM new
Dear friends of ours had a small business and opted to sign with Kaiser for health coverage as it was more economical.
They had a baby and all was well until about 3 months later when the mom noticed the baby's head was flat on one side. Pointed this out at a well baby check up and was told to place baby on opposite side to sleep. Mom followed orders but saw no improvement.
At four months she again asked the Pediatrician to look at the baby's head but he said the baby looked fine.
By the time baby was 5 months old, the flat side was VERY flat and the opposite side of the head seemed to be growing outward. By this time, other people noticed the baby's head seemed almost grossly misshapen and gingerly asked the mom about it. She then went back and INSISTED the Dr. look again. He reluctantly agreed to order a skull X-Ray. Next day he called her and told her it looked fine.
Well, by 6 months that poor baby looked really bad. Even strangers gave my friend sorrowful looks after seeing the baby so she began to panic. On her own, she made an appointment with a neurologist at Rainbow Babies & Children. At the scheduled appointment, when the doctor walked into the room, she said his eyes bugged out and and he cried, "How long has he been like this?"
Here, this poor baby had cranial stenosis, a condition where the bone sutures in the skull begin to fuse together prematurely. One side of his skull closed up so the growing brain was pushing out the side that still had open sutures. Had she not seen the neurologist when she did, the baby could have suffered brain damge, blindness, or other serious injury.
As it was, they scheduled surgery that very week and the operation to open the sutures was successful. The parents are very grateful that he will be OK but they, as well as those of us who know them, are incensed that the original health care providers kept ignoring her requests for help. The doctors at Rainbow said it was very obvious what was wrong with the baby and any competent doctor could have seen that.
I think the HMO doctors just hate to order tests or refer you to a specialist because the they are constantly being pushed to limit what they do. It's a real shame that we have such knowledge and technology available in this country and we are being restricted from accessing it by people who are not health care professionals, but BUSINESS people who only see dollar signs.
posted on December 26, 2000 07:56:26 PM new
there is a series of books put out by a group called Public Citizen that lists over 17,000 "Questionable Doctors". these are doctors who have had their licenses suspended or revoked, or have had other disciplinary sanctions against them. the offenses range from amputating the wrong leg, to drug addiction to sexual assault on patients to over- or mis-prescribing medications. very scary stuff. it is definitely not just HMO doctors who put patients' lives in danger.
posted on December 26, 2000 09:17:12 PM new
Yikes... that's terrible stuff! And I can see why an extra $750 a month would be prohibitively expensive. When you look at it that way, it's almost more important to get a job with good benefits rather than a better salary. Health is the most important thing we have.
I feel really lucky that my employer pays for HMO or PPO, our choice. We get an "allowance" every pay period which covers either, with money left over to go into a flexible spending account if we choose a less expensive plan. I'd be really scared to be in an HMO after hearing all this.
Edited to add: Speaking of Zithromax, I took it last week for an infection near my eye. The first dose made me really sick but it sure did work. I woke up the next morning and it had literally knocked the infection out -- I looked like someone had given me a black eye! And of course I had to go to my husband's office Christmas party that evening looking like I'd been socked.
[ edited by RainyBear on Dec 26, 2000 09:21 PM ]
posted on December 27, 2000 12:05:47 PM new
As a patient, I've had ZERO problems from my HMO. I've been fortunate to have primary care physicians who were intelligent enough, and not to proud to refer me to specialists when a problem was beyond their scope of expertise.
On the other hand, as a manager in a large cardiology, the same HMO is a royal PITA. Lab procedures that are commonplace for cardiology setting, such as lipid profiles, cholesterol levels, etc, we are not allowed to perform. Instead, we must send the patient to one of two local hospitals (their in contract with the HMO) to get their bloodwork done. However, lab procedures that we ARE allowed to do under this HMO include pregnancy tests, STD tests, and pap smears!
Oddly enough, if I were being evaluated for chest pain, and possible coronary artery disease, I really wouldn't want a pap smear.
posted on December 27, 2000 12:17:26 PM new
lswanson- do you have an idea as to what the cost for a lipid profile, for example, would be at your facility vs. the hospital lab?
posted on December 27, 2000 07:52:43 PM new
I used to have Pacificare here (before it went out of business). "Highlights" of this HMO were...
1) Going in for shortness of breath and being told to breathe into a paper bag??? (later diagnosed as asthma, which they told me there wasn't any real treatment for).
2) Going in with severe chest pains and being kept in the waiting room for hours (later diagnosed as gallstones and required a surgical procedure---which they made me wait 6 weeks for, while I was in the most horrible pain).
3) Doctor found a breast lump and I had to wait 2 months to get a radiologist to scan it (luckily it was nothing)
After that, I switched jobs and got Kaiser. I've been very happy with them. No complaints at all. I pay 128 a month for my COBRA coverage and I am grateful to have it. Pre-existing conditions mean I would be paying over 300 a month for insurance on my own.
posted on December 27, 2000 08:27:50 PM new
These incidents are scary. Really scary and are exactly the reason I won't go to a HMO. We are lucky that we do have a choice although I think our insurance just went up $50 per month but we will keep it.
These HMO's bother me. I hear lots of people that like them very much but they are usually people that are fortunate that they have not had to use much.
bearmom,
That is terrible! You would think for prompt pmt they would have been glad to give you a refund.
hcross,
I am so glad to hear she is doing better! It sure is scary with children though, isn't it?
We have been through the same Iv's, croup tents etc with out GS and it is not fun to watch a little one be so ill.
The kids have had a hard time even with insurance. During one episode he was in 1 ER two times which happened to be a military hospital and then sent to the local one by ambulance to the local one 50 mi away and was sent home. The next morning the first ER called the 2nd ER who called me to tell us to get GS back to the hospital because of a bacterial infection.
This was the 2nd time in 3 months that he had been in the hospital so they were getting bills from every little procedure you can think of. They do have insurance but the deductible plus the 20% for each place has really hurt them but hopefully with the new meds he can bypass the hospital because it will give them time to wait til morning to get to their family Dr.
I will say that all 3 hospitals or 4 when I have mentioned to the hospital that we must call for pre-admit the hospital has already taken care of it but I did tell the kids to always check and make certain.
posted on December 28, 2000 07:32:42 AM newStusi, the cost to the patient is the same. The cost to the HMO is the same as it is the HMO that sets the price structure rather than the health care provider. It should be pointed out that most HMOs are working hard to make Medicare pricing guidelines their own.
For procedures done in clinic, lab results are usually available the same day, the physician is notified of results, and the patient is notified in turn. Worst case is next day patient notification.
Procedures performed in the hospital require the patient to schlep to one more facility, register with the hospital's lab, fill out yet one more set of papers, and provide a physician's order to the lab. Actual test results which are usually available the next day may then take up to several days for delivery. So, instead of getting results the same day, possibly within the time frame of the office visit, the patient gets results delayed at least 24 hours if not longer.
So if the cost is the same, why does an HMO do this? By funneling the majority of lab services to one lab, the HMO is promising the lab a very large volume of work, thereby making the HMO's lower reimbursement more attractive to the lab. This may still seem like a stalemate costwise, but the HMO still benefits by winning the contract with a large lab facility. This makes the HMO appear to be very competent and more attractive to future clients, both patients and health care providers.
The original premise behind HMOs and PPOs and other simlilar "Os" was to be able to negotiate the cost of services in bulk, hence saving the patient lots of money, and yet still assurring physicians a good workload. Ultimately, the scheme has failed. Reimbursements to physicians are way down (another topic entirely). Too many primary care physicians are overwhelmed by the sheer volume of patients, and far too many primary care phyisicians are attempting to keep advanced cases in their own pocket. Patients
in need of specialized care are often "held hostage" by their primary physician and are only sent to specialists after their health has deteriorated severely.
Added into the whole mix is the fact that in many cases, we now have insurance companies determining the course of a patient's healthcare treatment based on a formula or flow chart. Physicians and healthcare professionals must go along with the programs or risk being bumped from the plans. In cases where the physician and the HMO disagree on a patient's care, rigorous documentation must be provided demonstrating why there was a change, and even then charges often have to be written off.
When managed health care first came to this region, many physicians pointed out the problems inherent in the system, and many refused to sign contracts. However, due to the wonderful rhetoric, many employers chose this route and the HMOs grew. Now they are in such a powerful position that physicians must either sign up or lose significant percentages of their patient population. Essentially, it's professional blackmail.
In sum, health care costs to the patient have not dropped as promised, the patient is now at the mercy of a primary caregiver's integrity, and in the end an insurance company determines the level of care that the patient will get. It's a failed system from start to finish. And we're stuck with it.
