Originally appeared in the September 1999 issue of the ABA Journal.
Heal Thy Self
BY ANDREW J. McCLURG
With Congress debating a patient’s bill of rights, it seemed like a good time to reprise one of the most requested Harmless Error columns of the last four years.
Legal disputes arising from the denial of medical coverage by managed health care organizations are on the rise. HMOs face a difficult challenge in making coverage decisions because they must delicately balance two conflicting interests: providing quality health care for their patients at a reasonable cost and hoarding as much money as possible.
Here are some of the more common questions about coverage and some standard responses from HMOs:
Q. How do I know if my condition is covered?
A. Check the “Exclusions” section of your plan description. Typical services excluded from coverage include dental care, cosmetic surgery and anything costing more than ten dollars. Our preferred method for determining whether a condition is covered is through an autopsy. However, before seeing a coroner, you must get a referral from your primary care physician.
Q. Is mental health treatment covered?
A. Are you crazy? That stuff is expensive. However, to serve the mental health needs of our loyal plan participants we’ve set up a therapy help line. Simply dial our toll free number and select from the following menu of sensitive pre-recorded treatments:
1. Quit Your Whining.
Q. Is Viagra covered?
A. Only under the extended plan. Ha. Kidding. The real answer is: NO. Due to rising pharmaceutical costs, we’ve been forced to make minor adjustments in our prescription coverage. Effective immediately, the following prescriptions are no longer covered: the most popular drugs selected by physicians for effective treatment of the most common ailments suffered by human beings.
Q. How can I get in to see an “Out-of-Network” provider as described in my plan?
A. You can’t. That’s a typo. The coverage is for “Out-of-Work” providers. They’re much cheaper.
Q. What happens if coverage is denied, but I desperately need treatment?
A. We recognize the need to resolve coverage disputes expeditiously. For this reason, we’ve established a speedy automated appeal procedure.
Step one: Request EZ Complaint Form 5436.
Step two: Fully complete all 72 pages, including attached “Humiliating Intrusion Into Your Personal Life and Medical History Form 7435.”
Step three: Conveniently deposit the completed form in any nearby trash receptacle. While you relax in the comfort of your home, your claim is being automatically processed and denied.
Q. I’m blind. Does your company show special sensitivity in handling claims by the sight-impaired?
Q. My plan excludes coverage for pre-existing conditions. What does that include?
A. The new industry-wide definition for pre-existing condition is: “Any illness, disease, infirmity, malady, affliction, ailment, injury, sore throat, cough, scraped knee, fever, infection, broken bone, concussion, kidney stone, pregnancy, tumor, hemorrhage, psychosis, missing limb, ache, pain, or gripe of any kind arising on or before the date on which medical treatment is sought.”
Q. Does my plan cover home visits by a designated provider?
A. Ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha, ha … stop, you’re killing me.