Health Administration Responsibility Project

About this site HARP is a resource for patients, doctors, and attorneys seeking to establish the liability of HMOs, Managed Health Care Organizations, and Nursing Facilities for the consequences of their decisions. We are concerned that in the headlong rush to "Efficient" Medical care, the organizations involved are losing sight of the "Quality" of the care they provide. As more and more "Incentives" to cut back on medical care are put in place by the new class of medical entrepreneurs, the patient often suffers. We feel that Counter-incentives must be applied, and they must be financial. The only such Counter-incentives available under our system are lawsuits for damages caused by excessive cost-cutting measures. However, many obstacles protect corporate providers from being held responsible for their acts. ERISA drastically limits the remedies available to injured workers, as well as preempting State regulations designed to control the more egregious problems. Rigged Mandatory Arbitration gives injured patients the illusion of justice. Strict application of state Tort laws holds doctors responsible for actions forced on them by Managed Care Organizations, which themselves escape liability. In an attempt to alleviate some of the obstacles to just resolution of patient suits, we have developed a Political Agenda which we will attempt to see enacted. We have collected here some aids for the plaintiff and his attorney attempting to surmount these barriers. We have links to pertinent sections of the Federal and California Codes, relevant Cases, other helpful sites, and musings on theories of liability. We also support a listserver where questions and ideas can be posted and discussed. But first you must Join as described Here. You will find many gaps here, and perhaps even some errors. Your ideas, suggestions, comments, criticisms, and assistance are earnestly solicited! Obviously if you have a specific legal problem, you should consult a lawyer knowledgable in the field. These pages are educational. They are not designed as, and should not be used as a substitute for, expert legal advice. We plan to set up a Legal Aid Society for patients injured by their HMO. If you would like to make a tax-deductible contribution to the War Chest, either now or in your will, you will need to know that our Tax ID number is 23-7406164, and our address is: HARP 552 12th St. Santa Monica, CA 90402-2908 Thank you! If you would like a confirmation letter, please ask us when you send your contribution. Note: There is another healthcare site with "HARP" in its name, entirely unrelated to this one. If you were searching for "Healthcare Accounts-Receivable Processing", you can find it at www.quadax.com/harp Theories of Organization Liability Structural Obstacles to a Trial on the Merits Sources of the Law Fighting a denial Consumer Resources Physician Deselection Recent and Pending Legislation Relevant articles from elsewhere Other Relevant Web Sites HARP's Political Agenda The Dialog Listserver Theories of Organization Liability Tort Contract Fiduciary Breach Consumer-Oriented Statutes Attacking License of Utilization Review Physicians Arizona, Missouri Relatively Untested Federal Causes of Action Qui Tam suits under the Federal False Claims Act Americans with Disabilities Act (Discrimination against the chronically ill) Structural Obstacles to a Trial on the Merits ERISA Mandatory Arbitration Deference to HMO's Decision MICRA (in California) Sources of the Law Cases Federal Statutes & Regulations Overview of Federal Programs Medicare Medicare.gov, The official Medicare page Other General Medicare Information: - from Medline - from SSA - links from SSA - links from CMS - Medicare Interactive Medicare On-Line Manuals MediGap policies, from Medicare.gov CMS Regional Offices, scroll to bottom of page and download pdf for contact info Health Assistance Partnership Medicare Resource Guides Medicare Basics - Medicare Advantage - Medicare Drug Benefit - Medicare Manuals Hospital Quality Comparisons Nursing Home Comparisons, from NIH Medicare Prescription Drug Benefit, from Kaiser Family Foundation Medicare End Stage Renal Disease Program, from American Association of Kidney Patients Medicare Downloadable Databases Consumer Alert, FTC re possibly fraudulent Medicare Part D prescription drug plans. Medicaid Medicaid Information: from CMS - from Medline - from SSA the Medicaid Law Some State Medicaid Websites: AL - CO - CA - DE - GA - MI - MS - NC - NE - NY - OH - TX - UT Medicaid and Pregnancy: from American Pregnant Assoc. - from Neighborhood Legal Services Rules for Medicaid Trusts Other Federal Systems PPACA, Patient Protection and Affordable Care Act, "Obamacare"    ObamacareFacts.com Social Security Home Page, SSDI and SSI US Railroad Retirement Family and Medical Leave Act: DOL site -- Assistance with filing (click on pause to stop annoying video) Medicare vs FEHB COBRA, temporary continuation of group coverage Dept. of Labor, site on health plans and benefits Federal Laws re Nursing Homes Medicaid Provision: 42 U.S.C. 1396r(b)(4) Medicare Provision: 42 U.S.C. 1395i-3(b)(4) Federal Regulations: 42 CFR 483.25 Rights to buy and keep health insurance by State Federal Employees Health Benefits Program - (Statute - Regulations) State Insurance Law Digests Comparison of State HMO Liability Laws (as of 2001) California HMO and Insurance Laws Knox-Keene Act Contents of Article 5, Standards Categories and standards of IMR Sections preempted by Medicare+Choice HMO Laws & Regulations, DMHC site Ethics Rules for Arbitrators Unfair Insurance Practice Laws Unfair Competition Act, BPC 17200 Consumer Legal Remedies Act, CC 1750 et seq General Construction & Definitions Deceptive Practices Remedies & Procedures Precis of AB55 & SB 189 Right to sue HMOs for negligence (CC 3428, nee SB21) Right to get Price information from Hospitals (HSC 1339.50 et seq) Hospital Charges Data Patient's Right to see & copy his Medical Records Dealing with recalcitrant HMOs in California Some notes on Kaiser, Birth injuries, and Record Fraud Bill Campesi's website documenting Kaiser Record Fraud, and More! State-by-State Guide from Georgetown University Whose Data Is It Anyway?, from California HealthCare Foundation Laws re Nursing Homes Civil Penalties Criminal Penalties Nursing Home Injury Laws by State Delaney v. Baker Gregory v. Beverly Enterprises Covenant Care v. Inclan Norman v. Life Care Dept. of Health Services site on Rights of Nursing Home residents Healthy San Francisco Medi-Cal Calif. Disability Insurance (SDI) Some State HMO Laws Pennsylvania Health & Safety Code HMO Chapter Access to Medical Records Texas Medical Practice Act, Excerpts. Health Hippo Your rights when your health plan changes - for any reason Some notes on "subrogation" Fighting a denial In General Top Unconscionable Practices Insurers & HMOs Use to Deny Claims California DMHC complaint form or here Contacts, by State, from KFF California Patient Guide from FTCR. Getting "Independent Medical Reviews" in California How to get a Second Opinion Outside your HMO California Law on HMO Legal Liability (CC 3428) Sample Letters To Your HMO Record Request after denial of ERISA benefits. Form to construct 'Request for Plan Information' letter. This is an experiment, based on the CHCR letter. When you get to the page with the letter, you can use the usual menu controls to set page format and print it, or use the 'back' arrow to make changes. Or you could save it and edit it. Navigating a Managed Care Denial by the Medical Board of California Handling the Demand for an "Insurer's Medical Exam" A letter from the Calif. Insurance Dept. to an HMO which had unfairly denied LTD to a CFS patient Tips from Fight Back & Win by Wm. Shernoff HMO Hardball. Useful tactics and Form Letters. Tips from "Making a Killing" from FTCR Advice for Members of Managed Care Organizations by David Trueman Some advice for Pro Se plaintiffs When HMOs quote "Guidelines" from WJM An unsuccessful attempt to make DMHC do its job Office of Kaiser's Arbitrator in California ERISA HMOs What ERISA Means by "Equitable": The Supreme Court's Trail of Error by John H. Langbein Erisa Litigation Fundamentals by Robert A. Perez Sr. Challenging ERISA Denials by Edward Connette Litigating an ERISA case without a Lawyer Sample Pleadings re Proton Beam Rx for Prostate CA. A very convincing argument by Sharon Arkin for liability of HMOs of Insured plans. Newer Strategies to avoid preemption Blair Brininger's LTD Claims Blog The Problem Is Erisa Blog by Richard Johnston LTD site for Pro Per's with CFS Medicare and MedicAid Medicare Appeals Process Medicare Appeals Manual, The full answers are here, if you can dig them out. Center for Medicare Advocacy, they will sue Medicare if necessary HICAP Offices in California Traditional Medicare Appeals, from Health Assistance Partnership Medicare HMO Appeals, from Health Assistance Partnership Medicare does NOT preempt State claims Medicare Appeals by Edward M. Dale Grijalva v. Shalala Sets standards for Notice and Review. Upheld by 9th Circuit in Jan.98 Social Security Disability Insurance Applying for SSDI Benefits by Janie Laubscher Alec Sohmer's SSDI page Scott Riemer's DisabilityClaims.com Reddick v. Chater, a 9th Cir. case explaining evidence standard. A Lawyer referral service for SSD cases (25% contingency fee) Disability Insurance Primer on Group Long-Term Disability Policies (pdf) by Linda Nee A Ten Step Guide for Disability Claimants by Linda Nee Linda Nee's Monthly Newsletters (HTML versions load faster, PDF may be prettier) FAQ from Dell & Schaefer Articles on Disability by Edward Comitz Nursing Homes Medicare Nursing Home Comparisons Ratings and survey results. Calif. Nursing Home Regulator Calif. Long Term Care Ombudsman Calif. Advocates for Nursing Home Reform Calif. Rights of Nursing Home residents Nursing Home Alert, Lawyers's site, nationwide information. Using the False Claims Act by Mark Kleiman Consumer Resources HealthCare.gov, individualized advice on public and private health insurance plans and clinics. Low Cost and Free Medical Clinics State Insurance Commissioners State High Risk Health Insurance Pools Finding Health Insurance Coverage in your State Organizations that Help Medicare Insureds in Your State Organizations & Hot-Lines (Mainly California) Calif. Dept. of Health Care Services (Medi-Cal) Attorneys Legal Document Assistant (AZ & CA) (for inexpensive Living Wills, and Health Care and General Durable Powers of Attorney) Small Claims Courts, by State Consumer Advocates (Non-attorney) Claims Assistance Professionals Legal Aid & Pro Bono Lists Doctor Lookup      Drug company payments to Doctors Compare Hospitals US Health & Human Services Joint Commission Hospital Inspections Reports Leapfrog Group, voluntary, so incomplete Hospital Safety Score California HealthCare Foundation Medicare Dialysis site Health Grades, Inc. Best Hospitals, U.S. News & World Reports Compare Medical Costs Medicare Charge-data Comparisons Typical Medical Costs California Hospital Chargemaster files Health Care Bluebook Fair Health, listed by procedure and zip New Choice Health Save On Medical, MRIs, X-rays and CT scans citehealth.com, Reports on specific hospitals, nursing homes, etc.(I found it void of information) Nursing Home Sites Non-medical in-home assistance and assisted living facilities Other Aging related sites Free Medical Flights, Google search, for State "Angel Flight" organizations Finding a Clinical Trial National Guideline Clearinghouse Private Medical Research for Patients FTCR's California Patient's Guide Avoiding Hospital Mistakes Helpguide for mental health and aging Your Legislators Federal Health-Care related Form Downloads RxWiki Consumer Reports Best Buy Drug Site Calif. Medicare Maximum Drug Prices Free Drug programs for low income patients State Programs RxHope NeedyMeds Helping Patients.org RxAssist.org Help with Co-Payments $4 Generic Drug Programs (as of 2/2011) These 4 pharmacies all have the same policies for generics - open to all, no annual fee 30 day supply- $4, 90 day supply- $10 Kroger, Target, Walmart, Sam's Club Drug Price Comparisons for American on-line pharmacies PharmacyChecker.com, searches US, Canadian, and international sites List of Rogue On-Line Pharmacies Get prescriptions filled cheap in Canada. This list has been deleted. Use the PharmacyChecker link. Big Pharma tries to raise suspicions about Canadian Drugs: www.buysafedrugs.info Eyeglasses at (very) low prices: 39DollarGlasses Eyeglass People Global Eye Glasses Glassy Eyes Blog Visio-Rx Zenni Optical Medical Care Abroad - Price Comparisons (pdf file) NOTE: HARP merely lists these organizations for your convenience. We have not investigated any of them. Be sure to do your own due diligence before committing to anything. All Medical Tourism Bumrungrad Hospital, Bangkok Fly2Doc, Spain & Portugal Health Tourism Joint Commission International Max Healthcare, India Medical Tourism MedPath Group Planet Hospital Surgery Overseas Taiwan TicketMed World Med Assist Avoiding Fraud Stop Medicare Fraud Avoiding Medicare Billing Fraud FBI Fraud Warnings for Seniors Preventing Home Improvement Fraud Preventing Identity Theft Preventing Credit Card Fraud Thanks to Rebecca Muller at educatorlabs.org for this list When all else fails, Laugh! Fired Doctors Fight Back Harper v. Healthsource (NH, 1996) Potvin v. Met. Life (CA, 2000) Schulze v. Humana (TX, 2000), news report Recent and Pending Legislation Federal HMO Bills proposed in recent Congresses California Relevant Bills passed in 2001 AB 1751 (Kuehl) to outlaw mandatory arbitration in health insurance & HMO contracts. KILLED BY THE HMO INDUSTRY! Look for its reincarnation as an initiative in 2002! Bills passed in 1999 SB260 - Limiting Capitation Contracts Bills passed in 1998 New Jersey Texas sb386, Suing HMOs, SB386 The District Court case which overturned most of it The 5th Circuit case which agreed A 7th Circuit case reaching the opposite conclusion sb1468, Doctors' negotiation groups Washington SB 6199, eff. 7/1/2001 (Thanks to Gary Preble for these links) While the Act was codified in several different places, it would appear that the meat of it is found at the following: 48.43.500 Intent -- Purpose -- 2000 c 5. 48.43.505 Requirement to protect enrollee's right to privacy or confidential services -- Rules. 48.43.510 Carrier required to disclose health plan information -- Marketing and advertising restrictions -- Rules. 48.43.515 Access to appropriate health services -- Enrollee options -- Rules. 48.43.520 Requirement to maintain a documented utilization review program description and written utilization review criteria -- Rules. 48.43.525 Prohibition against retrospective denial of health plan coverage -- Rules. 48.43.530 Requirement for carriers to have a comprehensive grievance process -- Carrier's duties -- Procedures -- Appeals -- Rules. 48.43.535 Independent review of health care disputes -- System for using certified independent review organizations -- Rules. 48.43.540 Requirement to designate a licensed medical director -- Exemption. 48.43.545 Standard of care -- Liability -- Causes of action -- Defense -- Exception. 48.43.550 Delegation of duties -- Carrier accountability. Relevant articles from elsewhere The True Cost of Healthcare, by David Belk MD An American Doctor's Experience in the Canadian Health System by Charles Phillips MD FACP Conflicts and Tensions of Complaint Managers, a dissertation by Clare Xanthos Fear & Loathing in the Kingdom of the Ombudswoman by Arlan Cohen MD JD      Kaiser OIA Reports Accountability and Fraud in Arbitration Proceedings by Michael R. Brown A Harvard Law Professor Blows the Whistle on Mandatory Pre-Dispute Arbitration, Senate Judiciary Committee, 7/23/2008 The Manipulation of HMO Medical Testing by Charles Phillips MD FACP An HMO explains its techniques for decreasing utilization.      Kaiser purposely makes it hard to see doctors, L.A.Times, 9/1/2001      Kaiser purposely prolongs ER Wait Times to drive patients away, appellate decision posted 12/20/2007 Lyme Disease: Two Standards of Care, by Lorraine Johnson Saving state law bad-faith claims from preemption by Donald T. Bogan, 4/2003 Criminal Prosecution for HMO Treatment Denials by Prof. John Humbach Sharon Arkin's Congressional Testimony, 4/24/2001 Promoting Accountable Managed Health Care: The Potential Role for Consumer Voice by Marc Rodwin Standards of Care and Standard Form Contracts: Distinguishing Patient Rights and Consumer Rights in Managed Care by Wendy Mariner The Judicial Reinterpretation of ERISA by Wayne Blackmon HMOs-Licensed to Kill a serial book, by Charles Phillips M.D. Some notes from Inside Kaiser's Emergency Room, by Charles Phillips M.D. Managed Care Ethics by Linda Peeno M.D. The second coming of managed care by Linda Peeno M.D. ERISA is a failure of the Democratic Process. by Prof. Rand Rosenblatt Rep. Ganske's letter to Congress. The Accelerating Marketization of the UK’s National Health Service, by Allyson Pollock, from MM 10/2004 Elderly HMO patients are twice as likely to have health decline as fee-for-service patients from JAMA. HMO patients are twice as likely to die in-hospital from an acute myocardial infarct as fee-for-service patients American Heart Assoc. Meeting, Nov. 1997 For-Profit HMOs are worse than Non-Profits, from JAMA, from NEJM For-Profit Nursing Homes 46.5% worse than Non-Profits, Amer. Jnl. of Public Health, Sept., 2001 480,000 Californians denied Health by HMOs in 1996, from Univ. of Calif. at Berkeley 87% of doctors report HMO care denials from Kaiser Family Foundation Study Compromising your Drug of Choice How HMOs are dictating your next prescription by Mark Green, NYC Public Advocate. The Truth about the Drug Companies by Marcia Angell HMO Negligence is Hard to Fight by Jane Bryant Quinn. Op Ed article on ERISA by Ron Hoffman and Mark Hiepler. HMO Executive Salaries Piercing the Armor: Approaches to Managed Care Liability by Thomas W. Williamson, Jr. and Joshua Silverman Frontline's HMO Documentary (April 14, 1998) L.A.Times Series on Workers Comp Anti-Fraud Campaign: 8/6/00, 8/6/00 Box, 8/7/00 HMOs deny Appropriate Care from NEJM 11/16/2000 Head of major financial group advises seniors to get out of medicare HMOs. HMO Experts avoid HMOs for themselves Morphine Hotel by Chuck Phillips Banner Week for Kaiser Negligence, Corruption, and Fraud New tools make it easier to find prices for medical procedures, L.A.Times Send a message to Dialog, our HMO Listserver. (be sure to Join first) Click Here To Join the Dialog Listserver. Click Here To Quit the Dialog Listserver. To get the Digest, go to your control panel once you've subscribed Minimal graphics are used on these pages to maximize accessibility to screen readers used by the visually impaired, as well as to minimize load time for everyone. Most of this site is continuously under construction. We welcome all suggestions and comments, whether substantive or technical. No information is collected about users of this site. No cookies are stored. Email addresses of list-members are not made available to 3d parties in any way. The site is funded by private individuals, and accepts no advertising or payment for any listing, except those ads placed by Google on the Site Search page. HARP has no control over and does not endorse those ads. These pages are up-dated piecemeal from time to time. A "last update" notice does not mean that everything on the site is current as of that date. This page was last updated on 4 Apr., 2011 This site complies with the HONcode standard for trustworthy health information Awards California Nurses Association Mishpat-Net Award Britannica Internet Guide Award This site is a member of WebRing. Top of Page Menu Webmaster: Our Board of Directors