Perspective               

Medicare Rights Center Charges That HMOs Continue to Mislead Public On Health Care Benefits

While stories mount about HMO's misleading and inaccurate information, HMOs continue to distribute literature that confuses people on Medicare about their health care benefits. A report by the United States General Accounting Office looked at 16 HMOs and found that nearly half of them "distributed materials that incorrectly described benefit coverage and the need for provider referrals."

"Nine months ago the Medicare Rights Center identified HMO misinformation as a critical problem in a report based upon case studies from our hotline," said Diane Archer, executive director of the Medicare Rights Center. "What the GAO report shows is that little has changed for the better in that time regarding HMO practices."

MRC's report, "Systemic Problems With Medicare HMOs: Case Studies From the Medicare Rights Center HMO Hotline" analyzed 179 cases handled between August 28, 1997 through February 28, 1998. The report shows that:

Forty percent (40%) of MRC's cases involved confusion by people on Medicare about their rights and benefits in Medicare HMOs, which was compounded by a similar lack of knowledge by HMO physicians and customer service staff.

Forty-nine percent (49%) of MRC's cases involved HMO noncompliance with Medicare laws, regulations and rules about appropriate care, coverage or a beneficiary's right to appeal.

"The GAO report has correctly identified a continuing problem with Medicare HMOs, one that the Medicare Rights Center confronts every day--people unable to get good information about their HMO rights and benefits," said Archer.  Archer recounted two recent examples from MRC's hotline illustrating the confusion that many people continue to face as they try to get health care services from their HMOs:

Mrs. R, 72-year-old woman who had both Medicare and Medicaid, was convinced by an HMO marketing representative to enroll in a managed care plan. He did not tell Mrs. R that she could see only network doctors and that Medicaid would not pay her Medicare HMO copayments. Mrs. R continued to see her regular doctors and specialists, and only realized that she was restricted to network providers when she received a bill for out-of-network services. MRC is working to secure payment either from the HMO or from Original Medicare through a retroactive disenrollment.

Mr. S called the MRC hotline after getting a denial for care out of his area. He said he went to two marketing meetings in Florida, where he lives during the winter months, and asked the HMO representative if he could still get care in the Northeast, where he spends the rest of the year. Mr. S says he was assured there would be no problem, and that pre-authorization for care was unnecessary. Several months later he was visiting New York and fell ill with pneumonia. He was denied services because he did not have pre-authorization. With MRC's help, Mr. S appealed, and the HMO overturned the denial and agreed to pay for care.

"The GAO report shows what MRC has been urging for nearly two years--that HMOs must make a better effort at clarity in their materials and in training and informing their staff as to patients' benefits and rights," said Archer. "What is at stake in this current confusion is the health and well being of thousands of people on Medicare."

The Medicare Rights Center's "Systemic Problems With Medicare HMOs: Case Studies From the Medicare Rights Center HMO Hotline" can be ordered by sending a $25.00 check to the Medicare Rights Center, 1460 Broadway, New York, New York, 10036.

Founded in 1989, the Medicare Rights Center (MRC) is a national, not-for-profit organization working to ensure that seniors and people with disabilities receive quality, affordable health care. MRC offers hotline counseling, educational initiatives, including public education through the media, and public policy analysis. More information about MRC’s programs can be found at http://www.medicarerights.org.

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