Managed Care HMOs

Don’t know what HMO stands for? Health maintenance organizations are managed care programs.

In terms of affordable health insurance, health maintenance organizations (HMO), which are managed care programs, assist people to stay in good health. At least that is the idea behind them.

Put another way, the philosophy of HMO insurance plans is that if a person stays healthy and maintains that health, they will prevent disease. The care provided by the HMO will help people stay well. Staying well means rising health care costs will be controlled.

When insurance plans like HMOs were first launched on the market, people who opted to buy affordable health insurance paid a fixed monthly premium that was prepaid. What those people got in exchange for affordable health insurance was access to health care offered by a certain network of providers that included clinics, hospitals and other medical care providers. This meant that although people were getting affordable health insurance, they were restricted to using “only” the procedures, benefits and doctors, etc. that belonged to the network.

HMOs were initially implemented by the government in 1973 to get rid of individual insurance plans and offer affordable insurance to everyone who wanted it. When they first came out, companies were buying individual health plans for workers.

Over time it looked like the better deal would be to get businesses to buy subsidized low cost health plans for employees and not expensive individual ones. Seeing a great opportunity, insurance companies started pressuring physicians to join HMOs. Fact is, doctors were told if they didn’t join, the insurance companies would see to it that they’d take their patients away with cheaper health care through the HMO. The threat worked and many joined the HMO plan to save their practices.

The more things change, the more they don’t always change for the better. What happened with HMOs is that every time a doctor renewed with them, the rules were changed and got stricter and stricter, mandated that they see more patients and get more services pre-approved. HMOs used to be the cat’s pajamas, but by the end of the 1980s and with a stack of unpaid and denied claims, people began to leave HMOs in droves.

The interesting thing here is that denied claims were denied because of bad investments the insurance companies made, not because of the claims themselves. The insurance companies invested in real estate, and when the boom went bust they couldn’t cover HMO claims. Unfortunately over time it became an almost “ritual” for HMOs to deny claims. So much so, that today it seems to be a part of the way they do business.

Thankfully, a new breed of attorneys has begun chasing HMOs for those denied claims; claims that include medical malpractice (med mal), bad faith and even wrongful death. In a nutshell, this boils down to the HMO may be sued if an individual dies due to the HMO denying cover for necessary medical treatment; for denying valid claims and for med mal perpetrated by an HMO doctor. In most states, government regulators are also tweaking their laws that govern HMO plans.