Managed Care Experiences 
Author Message
 Managed Care Experiences

I am interested in designing a training program for patients, physicians and
other health care personnel on how to advocate for the best care within the
managed care system.

I am interested in hearing experiences that people have had in the following
a.  denials of treatments because they were considered "experimental" by the
managed care organization (MCO).
b.  denials of treatments because they were considered not medically
necessary by the MCO, or for any other reason.
c.  denial of payment by the MCO for any reason.
d.  denial of stay or shortened stay in a health care facility for any
e.  denial of a health care service, e.g.:  home health care, medical
equirement, etc.
f.   termination of a health care service, e.g.:  ending of treatments,
ending of use of equipment.
g.  denial of non-generic perscription coverage.
h.  denial of admission to a health care facility.
i.  denials of treatment for mental illnesses.
j.  denials of treatment for a specific condition (HIV, diabetes, etc.).
k.  utilization review headaches.
or a patient's symptoms/condition worsen, was your credit ruined, as a
provider did you have to take a loss in fees for treatment, etc.).

Additionally, I would like to hear about any remedies that people sought to
address their denials.  For example, did you or a patient of yours go
through a MCO internal grievance procedure, and what was the outcome, and
what methods were used.  Did you or a patient of yours appeal to a
legislative body or try to place any public pressure on the MCO, and what
methods were used and what results were obtained.

Further, if you are a provider, what conditions have your MCOs placed on
you:  gag rules, treatment restrictions, etc.  What remedies/recourses do
you have if you disagree with the treatment plan recommended by the MCO?
Have you ever acted as an advocate in any manner for a patient dealing with
a denial or refusal of treatment, including writing letters of support,
speaking with utilization review personnel, case managers or medical
directors.  What were the results of your advocacy attempts, both in terms
of the treatment/payment outcome and in terms of your feelings as a

If you don't feel comfortable posting your response, you may write to me in

Thank you,
Rhonda J. Greenhaw
Milwaukee County Medical Society

 Also, you may join our e-mail dicussion group at

Mon, 05 Aug 2002 03:00:00 GMT
 [ 1 post ] 

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