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This one is about: Some Comments on Dealing with HMO's

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Some Comments on Dealing with HMO's: Parent asks -- Joanne Green, Wide Smiles responds:


Anyway, He is now in need of starting orthodontia. I have changed jobs and insurance groups since his last surgery (when he was 4 1/2). The problem is the HMO is trying to deny the referral to the orthodontist, claiming this is dental and not medical. Well, we all know that is not true. I have the feeling they are by-passing all the information and only seeing the words 'orthodontist', and that is why they are denying the referral.


Try getting the pamphlet, "Parameters of Care" from the Cleft Palate Foundation. That pamphlet lays out all the disciplines necessary for the adequate repair of a cleft, as recognized by the American Cleft Palate/Craniofacial Association. Highlight the parts you feel your HMO does not recognize and send that to them with yet another letter (I'm sure you have already sent many of them). To get the pamphlet, call 1-800-24-CLEFT.


Has anyone else had any trouble with HMOs. Any suggestions on maybe something like keywords or phrases that need to be used. Unfortunately our GP is new to HMOs as well and is having trouble trying to decipher their system.


HMO's can be a major pain. They are not subject to the mandates that cover insurance companies because they are not insurance companies (they are health management organizations). Anyway, what they generally like to avoid is fair hearing or going to court. When they lose, they lose big and are often mandated to make a service available to all their patients who fall under that category, so they try to make you happy before you challenge them (it's cheaper to treat one than to treat them all). So maybe a thinly veiled threat of litigation may do the trick.


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