Understanding the HMO Denial Process

The HMO denial process is slightly different from the PPO or FFS denial process. If your HMO has denied services or if you disagree with the payment of a claim by your HMO, you would submit your request to your medical insurance company to reconsider your request.

Once your insurance carrier has received your request for an appeal of your HMO denial, they will contact your HMO and request the rationale used to issue the denial. This information, in addition to information you have provided, will be forwarded to your insurance carrier’s Physician Advisor. Your request will then be reviewed to determine if it meets community standards of practice, EBG (Evidence-Based Guidelines) or medical policy. Your insurance provider may overturn the HMO denial.

Here's an example:

On Saturday morning of Memorial Day Weekend, at 2:00 AM, you were brought into the Emergency Department by your family member, in horrible pain. Thursday of that week, you had tried to schedule an appointment with your Primary Care Provider (PCP) to be seen for the complaints of pain when urinating but, the earliest available appointment was in three weeks.

That Friday you were seen by a physician's assistant (PA) at your HMO's Urgent Care clinic. At that time, you were diagnosed with a urinary tract infection and sent home on antibiotics. The problem became worse through the day until you felt as though you would pass out from the pain. That is when, on Saturday at 2:00 AM, your family member rushed you to the Emergency Department (ED).

The ED physician attempted to contact a renal specialist within your HMO. Unfortunately, due to the holiday, none were available. The ED physician requested a consult from an outside renal specialist who determined you did not have a urinary tract infection; instead, you had a huge kidney stone!!!!

The doctors agreed that you would not be able to pass the stone on your own. The decision was made to perform an emergency procedure to remove the stone. The procedure was a success and you were able to return home the following day.

You submitted your claims to your HMO but the HMO denied the services, stating you were not given authorization for the ED visit, or the evaluation and treatment by an out-of-network renal specialist.

You forward the HMO denial to your insurance carrier requesting an appeal of the group's decision. With your request you provided your insurance carrier with all the events which occurred and supported your need for the ED visit and emergency intervention of an out-of-network provider.

After obtaining information from your HMO and reviewing your information, the Physician Advisor from your insurance provider determined that you had a valid reason for seeking emergency care, that every attempt was made for you to be seen by a network specialist but, due to the holiday, this was not possible. The HMO denial is overturned and, all claims should be paid in full by your HMO as reasonable fees.


For this example, "IF" (that is a big "if") your insurance provider found in favor of your HMO by upholding the HMO denial, you could appeal your insurance provider's decision a second time. If your request is denied by your insurance provider the second time, you could request that the Department of Managed Health Care (for your state) review your request.

Again, it is important to remove the emotions from your requests for review and provide as much black and white, clinical information as possible when requesting an appeal!!!! You have 60 days to file an appeal.

What is considered to be a "grievance?"

Any issue related to the quality of care provided by your HMO is considered a "grievance." From firsthand experience I have seen "grievances" from members complaining about the "quality" of magazines available in their PCP's office. While this may seem like a "quality of care" issue, this "grievance" forces your HMO and insurance carrier to spend valuable time and money to respond to the complaint. In the bigger scheme of things, this is not a real quality issue!

While your insurance provider and HMO must follow the law and acknowledge the complaint about the quality of the magazines, other complaints about doctors performing procedures without enough anesthetic, the delay in receiving a referral to a specialist or the lack of wheelchair access are put on hold in order to review the grievance related to the "quality" of the magazines.

As a person who has once worked in the "complaint department" for an insurance company, I beg that you really consider if the quality of your care is suffering as the result of out-dated magazines, or chairs that do not provide enough cushion to meet your comfort needs. Your insurance provider receives hundreds of "grievances" a day. They really want to be able to help you. But, if they are weighed down reviewing complaints of "out-dated magazines", they cannot focus on real quality issues.

While you have 60 days to file an appeal of your HMO denial, there is no time restraint on when a HMO grievance has to be filed or reviewed by your insurance provider, although both the HMO and your insurance provider do try to expedite all grievances they receive in as timely a fashion as possible.

Remember, your HMO can file a grievance against you too!

While it may take some doing with a lot of paper work and proof on their part, if your PCP and HMO are able to prove you have been non-compliant with the group's restrictions/requirements and/or you have been abusive, your PCP and/or HMO may submit a request to your insurance carrier to have you removed as a patient of their group. Your PCP and/or HMO will have to provide you with adequate notice that they will no longer be providing you care.

If your insurance carrier determines that the group has sufficient evidence to support their request to have you removed as a patient, you will be asked to select another group/physician.

I can assure you that this has been done on quite a few occasions. And, after reading the evidence provided by the group, the physician and the antics experienced by the other patients in the waiting area, I can easily see why the requests were made and approved!

Needless to say, this all comes down to mutual respect.

Important Resource for State Insurance Regulators (state-by-state)

State Insurance Regulators for Filing Healthcare Complaints provides a state-by-state directory to help you find your state's insurance regulator. Go directly to the website for your state to learn more about how to file a complaint against an HMO or PPO provider.

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