Question

1. Under what conditions do you think it is appropriate for HMOs to deny coverage for treatments recommended by a physician?

Answer 1

HMO means Health Maintainance Organization is a Medical Insurance Group that provides health service foe fixed annual fee.

It is regulated at State level and federal level.

It operates in a variety of a form. It does not fit into any forms, have multipe divisions operating in different models or blend two or more models together .

Physicians are the one who has office in HMO. They are salaried by the HMO.. These contracted physicians may only see HMO patients.It is called as "Captive Group Model"

They cannot deny treatment by the physician..They cannot be held responsible or accountable for negligence.Most patient cannot sue the HMO if any denial or delay in treatment or any harm resulted out of the treatment offered by the patient.

The following are some of the conditions for the HMO to deny the treatment recommended by the physician

• If they are about to diconnect the Physician -Patient relationship
• If not an emergency case
• A prescription drug which is not on the approved list
• If patient denied treatment
• If treatment is completed
• No follow up needed
• If it is over the cost than the actual amount
• When patient keeps avoiding appointment or follow up