Covered Services, Outside Docs High on HMO Appeal Topics

February 19, 2003 ( - Most fights between HMOs and patients center on patients' ability to use out-of-network doctors as well as on which health services are covered, according to a new study.

Researchers at the Harvard School of Public Health in Boston found that the details of covered services and whether an out-of-network doctor offers a service an in-network provider cannot were two thirds of the HMO cases appealed for higher review, according to a UPI news report. Also high on the cases being appealed were those dealing with what procedures are medically necessary. The study involves data from two large California HMOs.

Quality of care was clearly a major concern since almost 60% of appeals by patients who sought out-of-network care did so because of quality issues, researchers reported.

In terms of decided appeals, about 40% of the overall cases ended in favor of the patient. The rate of patient wins was higher, at 50%, in cases that fell into the medical necessity category, the study reported . Appeals that patients lost often involved requests for elective or cosmetic surgeries, such as treatments for scars or benign lesions.

In their study, the authors suggest oversight authorities “hone in on the disputes with the greatest potential for harm” to patients. For example, review of cases involving medical necessity could be expedited and well scrutinized while less serious appeals for elective surgery or other procedures would follow another set of guidelines.

Researchers said a number of cases involved in the study were disputes over relatively minor matters.