HMO's and Prior Approval
Most HMO's work the same way and the doctor who is holding a lien against your father's estate, needs to be reported to the HMO he represents.
HMO's are not in the business to just allow any proceedure to take place and like most other insurance providers, there is a general list of proceedures that are allowed without the doctor seeking prior approval.
It is not the obligation of the patient to find out which proceedure is covered it is UP TO THE DOCTOR and HIS STAFF to get prior approval when dealing with an unknown area. The doctor assumed it was cover and since it was NOT.....it is not the patient's responsibility to cover for his mistakes. His STAFF should have checked the proceedure before administering or writing up prescriptions.
I would suggest that you send a certified letter to the HMO organization to the attention of an attorney (get the name of one that works for that organization) but send the letter to the Insurance Commissioner's office in the state that you reside in (again get the name of the insurance commissioner) present the facts to the insurance commissioner and ask for them to intercede for you in your father's behalf.
This action alone should get the ball rolling in your court as the insurance commissioner will contact both the doctor and the HMO provider and investigate the matter. Depending with the results from the commissioner's office, it will give you a better idea of what you are up against. It should reslove the matter as no doctor is going to go against the insurance commissioner's office and risk losing their credibility.
Terence J Donnelly CMBS (certified medical billing specialist)
[email protected]
