No one wants to be left without coverage these days, right? Doctors understand this very well, and are willing to help even in restricted fashion. See what boundaries get left behind in order to get HMO approval.
If you think the relationships among physicians and insurance companies are driven by respect and friendship, you are utterly wrong. There is quite a tension especially when doctors have to face denials on HMO. The possibility of an HMO denial, which has increased these days. in conjunction with the stress involved around it, forces many doctors to provide not quite relevant information about their patients just to get the needed approval. In case the HMO rejects the patient’s request, the physician can file and appeal to the decision, however the likelihood of an insurance company to change its initial decision is rather low.
Independent studies suggest that doctors are likely to lie about their clients’ actual medical condition in case there is a high probability that the patient will be denied with coverage or his/her condition is severe. The general situation here is the more likely an HMO is to deny coverage with the patient, the more willing a doctor is to change medical records and provide modified information about the patient’s condition. They are even likely to lie in the first place, if they know that the coverage is likely to be denied, in order to avoid the second appeal.
The main peril of such a practice, is that such an innocent and white lie will be reflected in the medical record. And if it’s quite positive in the first place, there may be very serious problems when the patient decides to switch doctors or a more serious health problem is developed. Having this in mind, it really looks like doctors helping patients with their lies just in order to get an HMO approval, are actually running them into a much greater risk in the long run, which may have far more serious complications than a denied coverage.
There were many suggestion on how to improve such a situation in a way that would please all the parties involved. But the more you think of it, the better you realize that it’s a matter of collaboration between doctors and insurance companies to provide cheap health insurance to their clients in a relevant and timely fashion. The need in an adequate dialog between HMO’s and doctors will further be a problem as long as there’s not enough cheap health insurance to meet the needs of everyday patients. And it’s hard to define which of the parties is responsible for such a balance disruption, because to seems to be a vicious cycle, threatening all the system in general.
The newly elect President has declared reforming the health insurance system as his priority and it may be the chance the whole system was waiting for. All we are left with is to wait and see, what measures will be undertaken to change such a practice we have become very familiar with these recent years.