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FIGHTING YOUR HMO: A FIRSTHAND ACCOUNT

It took Bob Sumoski three years, but he finally got his Medicare HMO to pay for the latex gloves he needs for personal hygiene. Sumoski, a paraplegic who lives in Lancaster, Calif., did it though a special appeals program intended to help Medicare patients who feel they're not getting proper care from their HMOs. Unfortunately, many of the 5.5 million patients who rely on Medicare HMOs will find the process complicated and time-consuming. ''It can get very frustrating,'' says Sumoski, 58.

I, too, have had experience battling the system--not for myself but for my late father, Herbert. Our dispute began when his HMO refused to pay for home health care beginning in August, 1996. Two years after his death, the case is unresolved. But I've learned how consumers can make the system work better for them.

UNENFORCED RULES. First, be aggressive. ''People don't know they have appeal rights, but it's their responsibility to know,'' says Diane Archer, director of the Medicare Rights Center (212 869-3850), which serves patients in New York City. Medicare has created a three-step process for most cases (table)--an internal HMO review, an appeal to an outside Medicare contractor, and a hearing before an administrative-law judge. HMOs are supposed to review emergency cases within 72 hours and resolve other disputes within 60 days. But federal Medicare officials who govern the insurers don't know how many cases are appealed within HMOs, how they are handled, or how long the reviews take. Patients who miss filing dates can lose appeal rights, but no HMO has ever been sanctioned for missing a deadline. Medicare will propose new rules in a few weeks to speed the process for non-emergency cases, but it has made little effort to enforce rules that now apply. That leaves patients on their own. Still, there are ways to improve your chance of a successful appeal.

If an HMO denies care or refuses to pay in full, it's supposed to notify a patient in writing and explain the review process. If you don't get a written notice, demand one. Then, get help. Navigating the HMO appeal maze is too much for many patients, especially those who are sick and frail. You can hire a lawyer who understands arcane Medicare rules, or contact a local Medicare rights group, which may have legal aides or experienced volunteers who can help. Call your local council on aging or Medicare's Hotline at (800) 638-6833 to get the number of a nearby organization.

Often, the mere intervention of an advocate is enough to persuade an HMO to pay up. ''If you know the system, the HMOs will pay attention,'' says Karen Reinhardt, who successfully managed the appeals process for two relatives and is now a volunteer advocate in Los Angeles. But whether you get professional help or not, pull together all the documentation you can, especially statements from your doctor demonstrating that the disputed care was medically necessary. Also keep notes of phone conversations with the HMO. Send copies of that paperwork with a letter to the HMO stating that you're appealing its denial of coverage and explaining why it should pay. If you're disputing a bill, tell your doctor or hospital, but do not pay it until it is resolved, says Eileen Harper, director of Medicare Advocacy at the Center for Health Care Rights (213 383-4519), which serves the County of Los Angeles.

At first, I tried to handle my father's appeal alone. But it took four months, and the HMO refused to pay any of the more than $20,000 in disputed costs. Once my appeal was denied, it was automatically passed on to the Center for Health Dispute Resolution, a private Medicare contractor based in Pittsford, N.Y. This year, CHDR expects to review more than 13,000 cases, up 45% from 1997. That's still a small percentage of HMO patients. Plan operators say that reflects satisfaction with their care. But patient advocates insist it's because the system overwhelms the old and sick. ''We are asking people to push for their rights when they are least able to do it,'' says Geri Dallek, project director for Georgetown University's Institute for Health Care Research & Policy.

The odds are about 1 in 3 that CHDR will overturn an HMO's denial of coverage. For cases that don't qualify as emergencies, CHDR is supposed to complete its review, based entirely on the written record, within 60 days. You have a right to your HMO file. But you must ask CHDR for it in writing. We had to struggle to get my dad's--it finally took a letter from our lawyer to CHDR. But the documents proved to be a gold mine. Indeed, CHDR ruled partly in our favor. But in order to get full restitution, I requested that the case be heard by an administrative-law judge. Judges who hear Medicare cases are federal officials who mostly review Social Security disputes but now are being trained in Medicare law.

WAITING GAME. Soon after I asked for a judicial review, I hired a lawyer. CHDR eventually agreed to reopen our case, after we presented some new evidence. Now, four months later, we are still awaiting a decision. If we lose, we are going to have to wait up to another year for a hearing.

It's a long, frustrating process. But every time Washington reforms Medi-care, it pushes more seniors into HMOs and slashes the amount of money that insurers receive for providing care. That means the appeals process will be an increasingly important part of life for the elderly and their families.

By Howard Gleckman
EDITED BY AMY DUNKIN



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