Denied Medical Care - Palm Beach Gardens Attorneys

Denial of Insurance Coverage - Florida Attorneys

The issue is the denial or delay of crucial medical care by an HMO motivated solely by the desire for profit. First, managed care companies tell their participants that their health coverage is based on "medical necessity." They explain that "medically necessary services" are provided when the "symptoms are appropriate with regard to standards of good medical practice." This is the single biggest category of complaints against managed care companies. The companies promise patients benefits "to the extent it is medically necessary," but define medical necessity in a manner that no responsible clinician would support. To the extent patients suffer from being denied medical care (including emotional suffering), they may have a valid legal claim against the managed care company.

Cohen Milstein Sellers & Toll PLLC, is at the forefront in representing patients who have been denied medical care and whose health needs are placed second to a corporation's profits. Located in Palm Beach Gardens, Florida, our law firm handles managed care lawsuits across the country.

HMO Policies Encourage Denial of Insurance Coverage

HMOs have internal policies and procedures that give direct cash bonuses and other financial incentives to claims reviewers who deny claims or limit hospital admissions and stays regardless of medical necessity. For example, in 1995 and 1996, Humana instituted programs to deny patients access to hospitals. Bonuses and incentives were awarded to case managers, nurses, and physicians if they discharged patients from hospitals earlier than the recommendations of treating physicians. These programs endanger the health of individuals while cutting corporate costs and increasing corporate profits.

'Secret' Criteria Used by HMOs to Deny Necessary Medical Care

Managed care companies pay third-party disease management companies to review claims for some medical conditions. These third parties use undisclosed criteria that are different and more restrictive than the disclosed "medical necessity" criteria used by managed care companies in making coverage decisions. In fact, during a trial involving a women with cervical cancer who was denied a hysterectomy, it was learned that Value Health Services, which was paid by Humana to review claims, had a policy of denying one of every four requests for hysterectomies - regardless of the patient's real medical condition. Value Health Services estimated that it saved its clients $67.5 million a year.

Treatment Caps and Staffing Restrictions Result in Substandard Medical Care

Managed care companies also subcontract with third parties to care for high-cost patients, those who are catastrophically ill and require continuous care, expensive treatments and long hospital stays. These companies, referred to as "carve out" companies, cap the care and treatment of these patients. Managed care companies reason that if high-cost patients are closely monitored, the cost of treating them will go down and profits will go up. However, when a managed care company decides to closely monitor one group of patients, they do so without adding new staff. Instead they shift personnel away from other patients, who are then left to suffer.

In Chipps v. Humana, Humana terminated over 100 catastrophically ill or injured children out of its Medical Case Management program in an effort to allow case managers to turn their attention and care to the costlier children who remained in their Medical Case Management program. Humana intended on saving money in two ways. First they threw out the high-cost catastrophically ill or injured child. Second, with the reduction of patients, Humana's case managers were allowed to focus their attention on the remaining children in medical case management.

Complicated Notice Requirements Make It Harder to Get Necessary Medical Care

Managed care companies also use accounting firms to recommend ways to make notice requirements trickier so care can be denied. Some managed care companies require their subscribers to obtain advanced approval for emergency care or to call a toll-free number within 24 hours of receiving emergency care. These "notice requirements" are usually buried deep in the policy where people can't find them so they can be invoked by the managed care companies to deny coverage when it otherwise should be provided.