Patients' disputes over HMO denials of coverage very often involve elective procedures, such as liposuction or varicose vein removal, rather than treatments with direct health consequences, according to a study in the Journal of the American Medical Association.
Reviewing pre-service internal appeals at two large California HMOs from 1998 to 2000, the study finds that most appeals involved extent of contracted coverage or access to an out-of-network doctor or hospital, rather than medical necessity decisions.
Further, disputes over medical necessity "frequently converged not around life-sustaining therapies, but in areas of ongoing uncertainty about the proper limits of insurance coverage," the study says.
Still, the study finds that enrollees won disputes involving medical necessity 52.2% of the time, compared with 35.4% of the time for disputes on out-of-network coverage and 33.2% for contractual coverage.
"Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care," the study concludes.