Case Flash: Out-Of-Network Urgent Care Should Be Covered By HMO

Mr. M. had a Medicare private health plan, an HMO. In November 2008, he went to the dentist to be fitted for dentures. The procedure resulted in swelling and an ulcer formed on his palate, and a biopsy was required. Because Mr. M could not find an oral surgeon in his HMO to perform the biopsy, his dentist referred him to an oral surgeon who was outside of his network. The surgeon billed the plan, but the request was denied because the oral surgeon was out of network. After the surgeon was denied payment, he asked Mr. M to pay the outstanding balance of $300. Mr. M paid, even though he didn’t think he should have to.

Mr. M called the Medicare Rights Center for help. A hotline counselor confirmed Mr. M’s suspicions: he was not responsible for the full cost of the treatment because his HMO is required to cover the cost of “urgently needed services,” even if they are received from out-of-network doctors. Plans consider services urgently needed—and thus will cover them—if they are required as a result of unforeseen injury when the patient is outside of the service area or the provider network (or the provider network is unavailable or inaccessible, as in Mr. M’s case), and it is unreasonable to require the patient to get the services from a network provider. The hotline counselor walked Mr. M through the steps of appealing, starting with reading the appeals directions that were included on Mr. M’s Explanation of Benefits, the document Mr. M received from his private plan telling him that it would not cover the services.

In March 2009, Mr. M won his appeal. Because his service was urgent, Mr. M was responsible only for paying his private plan’s usual $10.00 copayment. His HMO provider paid the physician the difference (up to the plan’s approved amount for the service), and Mr. M is awaiting reimbursement of $290 from the provider.

-From MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 12 , No. 14: July 15, 2009.

 

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