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Ask the Mental Health Expert Archives 2001-2004

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HMO

Q. How do you go about challenging the ruling of an HMO to discontinue treatment? Is there any set protocol that you would recommend?

A. Dealing with managed care organizations (some might say, mismanaged care) can be frustrating for both doctors and patients. Most HMOs have internal appeals procedures when benefits are denied. The first step is usually to tell your health plan about your problem in writing, as soon as possible. List all the relevant facts, and tell the HMO how you would like them to resolve the problem. Avoid accusations. There is a good sample letter you can find at the website of the Californina Medical Assocation (http://www.sonic.net/melissk/calmedcomplaint.html).

Your HMO will almost certainly respond to your letter by asking you to fill out a form, provide additional information, or speak with one of their representatives. You should keep copies of all such communications. If these steps don't resolve the problem, you might try contacting one or more health consumer advocacy groups, such as the Consumers Union, or The Center for Patient Advocacy (800-846-7444). If you are objecting to loss of mental health treatment, two agencies that could be helpful are the National Alliance for the Mentally Ill (800-950-6264); and the Bazelon Center of Mental Health Law (http:///www.bazelon.org/). While the whole issue of whether patients can sue their HMOs is under very active debate nationally, hiring a lawyer would certainly be a reasonable "last step" in the appeals process.

January, 2001

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