A program of
HMO Patient Advocacy League (HMO-PAL) is a pro bono program to
assist enrollees of Medicaid, Medicare, and ERISA HMOs who have been
denied needed care by their managed care plan. Its activites are currently
limited to the Los Angeles area, and patient accession is currently solely
by referral from existing community HMO Hot-Lines.
It taps the volunteer efforts of student, active and retired physicians, nurses, lawyers, social workers, medical librarians, and laypeople, and cooperates with existing community resources such as health-care hot-lines, law and medical schools, churches, hospitals, professional organizations, legal aid societies and social service agencies.
It has developed a “Treatment First” protocol whereby it hopes to enable patients to receive needed medical care early, while they are still able to benefit from it, while issues of payment are wending their way through appeals boards, arbitration panels, and courts. It is attached.
As the HMO has forced the doctor to become a "gatekeeper", whose income depends upon denying his patients the procedures, hospitalizations, and referrals to specialists that they need, the HMO patient has lost the one ally he or she traditionally had in battling the forces of disease and bureaucracy.
Regulatory agencies have not filled the void left by the doctor's forced disappearance from his position of patient advocate. They are understaffed, politicized, uninterested in consumer welfare, and unable to deal with individual cases rapidly enough to prevent harm to the patient from denial of needed care. The fines they may ultimately assess do nothing to help the injured patient.
It is difficult for these patients to obtain assistance with their appeals and arbitrations from private lawyers because the patients can't pay hourly fees, lawyers won't take cases on contingency in which fees may not be available, and government support of legal aid societies has essentially disappeared.
These patients are often old, non-english-speaking, poor, very ill, or have other problems making it difficult for them to represent themselves before an intransigent monolithic organization denying them the care they need. Subsequent tribunals often give extreme deference to the findings of these in-house reviews, so naive errors can doom subsequent appeals.
It is an anomaly that courts routinely expect the patient, who is appealling a denial to his HMO review panel, to research the medical literature and analyze his insurance policy himself, and present that information to the panel. Patients are normally incapable of mounting such a technical in-house appeal unassisted, and thereby lose both their appeal and any subsequent suit which will consider only whether the panel’s decision was reasonable in light of the information the patient supplied it.
HMO-PAL will assist these patients, referred by existing HMO hotlines, prepare their in-house appeals, and, if necessary, find alternate sources for needed treatment and attorneys to take their cases to court. The procedure is outlined in the appended protocol.
1. Patient denied services by Medicare, MediCal, individual, or Employer- funded HMOs contacts an existing HMO hot-line, which requests assistance from HMO-PAL.
2. HMO-PAL volunteer legal staff requests plan documents and analyzes them to see if the treatment reasonably should have been covered. If so -
3. HMO-PAL volunteer medical staff reviews the medical situation to see whether the treatment is really 'unnecessary', 'experimental', or whatever the putative basis for the denial was.
4. If HMO-PAL agrees with the HMO decision that needed care is nevertheless not covered, the HMO-PAL volunteer social work staff refers the patient to appropriate social agencies for alternative sources of care. Otherwise -
5. If treatment is urgent, HMO-PAL legal staff prepares an urgent in-house appeal. If unsuccessful, it attempts to obtain a Preliminary Injunction to have the care delivered. If unsuccessful,
6. HMO-PAL negotiates with a provider to provide the treatment for its marginal cost (not over 10%) plus assignment of patient's claim against the HMO.
7. If the patient can't pay even the marginal costs, HMO-PAL will attempt to advance them from funds obtained through public fund-raising.
8. HMO-PAL volunteer medical, librarian, and legal staff assists the patient to prepare and present requisite in-house appeals. If unsuccessful -
9. HMO-PAL will provide inexpensive party arbitrators if the contract calls for mandatory arbitration.
10. Provider helps with evidence and experts pro bono or for reduced fees.
11. If appeals are unsuccessful, HMO-PAL negotiates a reduced contingency fee with community attorneys or bar pro-bono committees to bring the case to trial.
12. If case is successful, provider gets the rest of its fee plus interest, less reduced contingency fee if no legal fees were awarded. HMO-PAL gets reimbursement of expenses.
Director: Harvey S. Frey MD PhD JD
Legal Director: Mervyn Hecht JD
Social Work Director: Doris E. Bass LCSW
Cooperating Physician Organizations :
Cooperating Law Schools :
Cooperating Attorney Organizations
Medical Research Services
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