HMO / Managed Care Claim Denials

A Health Maintenance Organization, or, “HMO,” is a type of health care plan that has become very popular in the U.S. in the last 25 years and our insurance attorney Delray Beach FL respects can decipher the policy language with these plans. The primary reason why HMO’s have become popular is cost. HMO coverage is typically cheaper to buy than traditional health insurance coverage. Like many things in life, however, cheaper isn’t usually better.

In exchange for a less costly premium, an HMO subscriber gives up some of the decisions regarding their care and treatment to the HMO. For example, in many HMOs the primary care physician – and not the patient – decides whether a visit to a specialist is needed. Without pre-approval from the primary care physician, the HMO will refuse to pay for the cost of care obtained from a specialist. In the past, many HMOs provided financial incentives to primary care physicians to limit patients’ access to medical specialists. Speak with an insurance attorney Delray Beach FL offers if this has happened to you.

Many HMO plans also exclude coverage for the cost of treatment received by a patient outside of the “network.”  A “network” is a group of medical providers who have agreed to accept certain terms of treatment and reimbursement specified by the HMO. These medical providers are often referred to as “participating providers.” Under these HMO plans, if you receive treatment from a medical provider (not “in-network”), then the HMO can deny payment for the services received from that provider.

Another way HMOs cut costs, to the detriment of the patient, is to claim that the treatment for care sought is not “medically necessary.” Often the individual making this determination for the HMO has never even seen the patient. In one case our insurance attorney Delray Beach FL relies on was involved in, the medical director of the HMO who made the decision to deny care was not even licensed to practice medicine in Florida.

If an HMO denies care to a subscriber, or fails to honor a claim in full, Florida law allows the subscriber to recover attorney’s fees if a lawsuit is successfully brought against the HMO. Thus, even if the amount in dispute is rather modest, a lawyer who is successful in helping a subscriber can recover their fee from the HMO for the time spent assisting the subscriber.

Insurance disputes, like insurance policies, can be complicated and difficult for most people to understand. An experienced insurance attorney Delray Beach FL residents count on can help you determine whether you have a valid claim. Please feel free to call me to discuss your case. The initial consultation is free, and you will speak directly with me, Eric Luckman, about your claim and your rights.

Eric Luckman is a Florida Board Certified Civil Trial lawyer. Less than 2% of lawyers in the state of Florida are recognized with this prestigious certification.  Board certification recognizes attorneys’ special knowledge, skills and proficiency in various areas of law and professionalism and ethics in practice.

Feel free to call our office to discuss your case. The initial consultation is free, and you will speak directly with Eric Luckman, about your claim and your rights.

An experienced insurance attorney Delray Beach FL respects can help you determine whether you have a valid claim.