Wednesday April 25, 2001

Things To Know About HMO's

A mother of two is forced to pay for her own hysterectomy. A bus driver's blood pressure medication switched without her knowledge. A loving husband dead at the hands of a negligent hospital staff.

From headaches to heart surgery, everyone has an HMO horror story. But there are ways to protect yourself. Smartmoney.com's Vera Gibbons says there are five important things you should know about your HMO.

1. Your primary-care doctor is in many cases also your specialist. Vera says, "The problem is many HMO's won't allow you to see a specialist no matter how sick you are."

Heart condition? You want a cardiologist. Sinus infection? You need an ear, nose and throat specialist. But many cost conscious HMO's will cut corners. Vera says, "So what you've got are primary care physicians doing procedures they're not necessarily qualified to do.

2. Your health can be treated like a numbers game. For example you've had a c-section and feel lousy. Too bad, you're out of the hospital in 48 hours. And even if you've suffered a stroke you're still going to have to leave the hospital within three days.

3. Watch out for second rate parts. Knee replacements, hip replacements, Vera says many savings-minded HMO's use generic and potentially inappropriate parts. She says, "Ask your doctor if you're getting the real deal or brand X. If he doesn't tell you, you know what the answer is."

4. Your time on the couch might not be covered. Vera says, "Some HMO's would prefer to give their patients medications and skip the therapy all together."

So what if you're unhappy with your HMO altogether? We've saved the worst news for last.

5. Don't try to sue. Vera says, "The industry itself is virtually immune to litigation."

You can't sue your HMO for poor quality. Punitive damages or pain and suffering. You can only sue if a procedure wasn't covered for the amount it cost you. So, seems the best prescription is to do your homework before heading to the doctor.