Many Americans today are covered by a health maintenance organization(HMO), but most Americans may not know that HMOs have more concern over spending as little as possible instead of their patients’ well-being.
What is an HMO?
A health maintenance organization is a type of health insurance program that provides you with a primary care physician (PCP) that will oversee your health and refer you to other medical providers that are approved by the HMO if needed. People often use HMOs over other forms of insurance due to HMOs typically a having lower premium.
The Problems That Arise From Being Covered by an HMO
The main concern for patients using an HMO is that usually, but not always, only the cheapest forms of treatment are covered. This means that an injury or condition that you have may not be treated with the best medical care because your HMO limits available treatment options to keep its costs down. HMOs also only cover what that they deem “medically necessary”, which means that they will only cover the basic treatment that they feel is necessary to heal your condition. For example, If you have a pain in your shoulder and your doctor suggests a surgery to treat the shoulder but another tells the HMO that you only need diet and exercise, your HMO may deny your claim for surgery on the basis that is was “not medically necessary.”
HMOs give their doctors and other medical providers a set amount of cash that is used to pay for treatments, referrals, tests, and other expenses, but the doctor or medical provider gets to keep what is left over as payment. This is designed to motivate doctors and other medical professionals to avoid expensive diagnostic tests and reduce treatments. While many doctors still do everything they can to treat your conditions or injuries, the financial motivation may influence some of their decisions to try to save money for themselves and the HMO.
An additional problem with HMOs is that the PCP that you use may not have the specialized experience needed to cover problems that you may have in the future. For instance, if you develop a back problem, your PCP will have to refer you to another specialist to get the best treatment. HMOs generally want to avoid referrals other than within the HMO itself and if the needed specialist is outside of the HMO, your PCP may try to handle the treatment himself or may refer you to a different type of specialist inside of the HMO in order to avoid the cost of the external specialist. It is also possible that the medical provider that you need isn’t on your HMOs list of approved medical providers, in which case your HMO may not cover your visit and subsequent treatment.
These are just a few ways in which HMOs use their control over patient medical care to increase their profits and decrease the standard of medical care that their patients are entitled to. If you have been wrongly denied to a claim by an HMO, that might constitute a bad faith denial of insurance benefits and you may have legal options. In that situation it is always best to consult with an attorney with experience handling claims against HMOs and insurance companies.