Getting Tough With HMOs

with Brooke Gladstone and William Shernoff

> GLADSTONE:
Even more than the legal profession, even more than I daresay, the media, the avatar of professional slime for the public on the eve of the 21st century seems to be the HMO. At least in the United States. This is OnHealth Live, I'm Brooke Gladstone.

I was sitting in a crowded movie house watching As Good As It Gets, and when Helen Hunt's character lashes out at her HMO, the audience of jaded Brooklynites burst into loud and spontaneous applause. Hating the institution of the HMO has become a national passion.

We are suspicious of HMOs because they literally hold over us, the power of life and death. Reasonable arguments about cost and efficiency are not received reasonably by parents whose child is suffering and when the arguments are unreasonable, we rage and then often, we sue. And that's where our guest comes in.

William Shernoff is a lawyer who specializes in these matters and author of the book Fight Back and Win, how to get your HMO to pay up. Welcome. Thank you so much for being here.

> SHERNOFF:
Thank you for having me, Brooke.

> GLADSTONE:
I'm gonna start out with a nice word about HMOs. This is from Chuck in Rhode Island. He said there's a lot of talk about fighting your HMO lately. I have had Harvard Pilgrim here in Rhode Island since actually there were Rhode Island -

- they were the Rhode Island group health association. I've received better care, had fewer problems, faster appointments and referrals than I did when I could select my own physician with Blue Cross. I had more problems with having to get second opinions with Blue Cross -

- and frankly my doctor's both better educated and a better physician overall. Why would I want to fight my HMO over the rude and slow pharmacist. There are a lot of HMOs that work really well, aren't there?

> SHERNOFF:
Well yes, there are some and also, I think most of them work pretty well for, like routine stuff. I think most people that go in for checkups for just routine illnesses - colds, flu, stuff like that, they're pretty good at that. I mean they're really -

- that's the name of the organization is a health maintenance organization. So I would say on maintenance they're pretty good, but the problem really comes in when somebody has a serious illness or injury that's going to cost some money to treat. And when that happens, people find that because of their cost consciousness and because they make more money by the less medical treatment they give, then it becomes a real problem because they don't want to refer to specialists -

- they don't want to give people expensive treatment like high dose chemotherapy for cancer or bone marrow transplants or -

> GLADSTONE:
I think we need to back up here and talk about what you've just referred to, which is the arcane structure of many HMOs. Let's start with capitation. This is a phrase that a lot of - a word that a lot of people may not know and yet it's at the heart of a lot of the problems with HMOs.

> SHERNOFF:
It really is. It's at the root of the problem. We should back up and, and start with what's called fee for service, which we were 10, 15 years ago, that caused the problem. That means that when there's a medical service performed, there was a fee for it.

So if a doctor took one x-ray, he got paid for one. If he took 3, he got paid for 3. If he took 5, he got paid for 5. So the incentive in the fee for service, a lot of people said was to give more treatment than was needed just to get money and it drove the cost of healthcare up.

And so then HMOs came on the scene and they said well we'll - we'll work on a different system. Which is capitation as you mentioned. But that's just as bad because that's the other extreme. That says you get so much money, let's say $500 per month per head to take care of a person. So if you don't give them any medical care, the $500 is pure profit. If you give $1000 a month medical care, you lost $500 on that person.

> GLADSTONE:
So now the motivation is to provide less service, rather than more.

> SHERNOFF:
Right and capitation really ought to be outlawed because in healthcare, we cannot have a system that gives incentives to people to deny medical care. That's just - seems like it's almost unAmerican. But it's going on and to make matters worse, many HMOs give financial incentives like bonuses or revenue sharing to doctors or administrators to deny medical care.

So that if they do deny the medical care, they're gonna make more profit themselves. And that's, that's really unconscionable in most people's minds.

> GLADSTONE:
Well what are the situations, the medical conditions that pop up most often in your practice? You talked about chemotherapy. What areas are particularly problematical to HMOs? I think you mentioned high risk pregnancies and chronic diseases - [BOTH SPEAK AT ONCE]

> SHERNOFF:
High risk pregnancy, chronic diseases, breast cancer where most of the - if it's advanced you need a bone marrow transplant and high dose chemotherapy, all kinds of cancer treatment which is very very expensive. Skilled nursing care which is expensive though they'll -

- they'll want to send somebody to a facility that is - is not really skilled nursing care. Rehabilitation is another area where people have serious serious injuries and they need to learn how to walk again or they lea - need to learn how to talk again. Instead of going to these really credible and good institutes that have these specialist rehab doctors, they'll send somebody to a - like a nursing facility that costs one half the price -

- but there's really no credible rehab at that facility. So almost anywhere you look when it gets to be specialized and expensive, the HMOs are, are really hard line and, and sometimes - and we've had cases like this, we just had a case last month where -

- where the treating doctor at the HMO and the specialist at the HMO recommended that our client get a special treatment for his stomach cancer and it took 45 days just to get approval for that. And by that time, his cancer had metatastized.

And he was in real trouble.

> GLADSTONE:
How can an HMO justify denying chemotherapy or bone marrow transplants? What, what reasons can they give?

> SHERNOFF:
Well they come up with all kinds of reasons. The main reason they usually come up with that I see in my law practice is they say it's experimental. And that they are not obliged to give experimental treatment. However, there's a couple problems with that.

In the case that I just cited, there was no exclusion in this person's HMO plan for experimental treatment, so they were really off base not paying for it when the plan itself did not exclude it.

> GLADSTONE:
Well what reason did they give?

> SHERNOFF:
Well they just said it was experimental and, and that was the end of, that was their reason. And many times it's the weight of the medical authority in this country is that it's not experimental. It's - it's routine. But you get into these arguments - whether it's experimental or not experimental. Whether it's investigational or not investigational.

Whether this is custodial care or it's really bona fide medical care. Whether the person really ne - needs the treatment as medically necessary. One of the big problems though is the - a lot of HMOs allow the administrators to overrule the doctors.

> GLADSTONE:
Well we have a question that relates to that so let me ask you, and then we'll go back and discuss the whole issue. Mary Lee in Florida wants to know, what steps should I take to get my insurance carrier Health Options to cover medications that are prescribed by my physician?

In one case, they stopped covering Voltarin[?] which has been covered for many years. My physician tried 2 or more similar medications that were covered but neither brought the same result as the discontinued coverage medication.

And she talks about how she strongly feels that no HMO or insurance company should be overruling her physician unless they all have medical licenses. What do you do over this medicine issue?

> SHERNOFF:
Well she's got a very good point because they shouldn't be overruling the doctor. And I'm sure that if - if she looked at the brochures that the HMO gave her when she first signed up, they probably had all these glorious promises in there that they would pay for all her prescription drugs that were recommended by her doctor.

And the problem is, they do these things and they by and large get away with it because they know they can't be sued for damages if something bad happens because of this ERISA law.

> GLADSTONE:
Right. Now before we get to the ERISA law, can you address a little bit, the first part of her questions. What steps should she take?

> SHERNOFF:
Well, I would first have the doctor who prescribed it, go to bat for her and - and go up the chain of command in the HMO and - and insist that these drugs that she's being prescribed by him be paid for. It sounds like there's just no valid reason for them to deny it unless it's some sort of a drug that's not approved by the Federal Drug Administration which I doubt from the question that that is the case.

> GLADSTONE:
Well we'll get to - we'll get to ERISA right after this, but we have another drug question which is related to it. This is from Muriel in California. When an HMO denies medicine or treatment because it isn't on the formulary or it's too expensive, how do you get them to approve it?

Now that's a good general question and you devote a lot of your book, Fight Back and Win to offering some steps.

> SHERNOFF:
Well yes. There - there's like 3 steps you can, you can appeal internally to their grievance procedure. Sometimes you can go up the chain of command in the HMO and make a lot of noise. Sometimes that will do it.

You could complain in California to either the department of insurance or the department of corporations and they might take up your cause. And you can go to the media sometimes and expose unfair business practice and sometimes that will get their attention. And of course what really gets their attention is lawsuits and if they're Medicare recipients, or if they are government employees or church employees, they can sue. Those are the 3 major groups that still have the right to take an HMO to court.

> GLADSTONE:
I see we'd better, we'd better get to this ERISA question at least for the first time right now. And I know this is a particular bete noire of yours. It's a restriction built into the regulation over these matters. People who belong to an HMO with certain exceptions, a couple of which you just mentioned -

- they can't, they can sue to cover the treatment, they can sue for the cost of the treatment or medicine they were denied, but they cannot sue for damages. And talk about when - when that law passed and what the impact of it has been.

> SHERNOFF:
Well that law passed almost 20 some years ago - it was a United States supreme court decision that, that basically said this law applies and the state laws don't apply. Unfortunately the federal law doesn't have any provision in it for remedies for damages.

So people who, who are not - fall into one of these exception groups, they haVe no remedy. And - and most HMOs know that so they can be very cavalier in their denials because you can't take them to task for it, other than through these procedures I've talked about.

Going to the media or making a lot of noise or going to the department of corporations. But what really concerns and scares an HMO is the threat of a lawsuit, because if they're denying somebody let's say a very needed drug that's prescribed by the physician and something bad happens to this person because they don't have the proper drug, they could be sued for a lot of money and damages if this person is injured or harmed by their decision to deny coverage.

> GLADSTONE:
I thought you said that you couldn't sue them for damages.

> SHERNOFF:
Well if they belong - you - you cannot sue them for damages unless you belong to one of these groups. But my point is, if they change the law which we're - which is now pending in congress to allow everybody to sue, all 125 million Americans who get their health coverage through their employment, then the HMO would think twice before denying that person the drug.

Because they know that they could be sued, so they would probably approve that drug, especially if it's recommended by the treating doctor.

> GLADSTONE:
So what is the, what is the status of this law as we speak and what's it called?

> SHERNOFF:
It's called the patients bill of rights. It's now being considered in the senate and it would give people the right to sue their HMOs. And would give people the right to choose their doctor.

It would give people the right to, to get a specialist when they need it. To get emergency treatment when they need it. It's a whole bill of rights for patients and it's very important. That's why I devoted a whole chapter in my book to that.

And even put in a sample letter for people to write their senator or congressman and try to convince them that this legislation is really needed.

> GLADSTONE:
There are a couple of case studies in your book. There was one about a health insurance company that decided to halt the coverage of specialized at home care for 7 - a 7 year old boy.

> SHERNOFF:
Right.

> GLADSTONE:
Ultimately the company had to pay more than a million dollars in emotional distress damages to the mother and son. Were these - was the mother and son among the exceptions?

> SHERNOFF:
Yes, the mother - the husband worked for the - a police, he was a police officer in one of the, one of the cities in California. And being a police officer, he worked for the city. And if you work for a government entity like a state or a city or a school district -

- or any sort of a government entity, you don't haVe this ERISA problem and, and so she was able to - actually we were able to get an injunction against the HMO to make them put back the lifesaving monitors on her - her boy. And also sue them for damages.

For basically attempting to take away his life saving equipment.

> GLADSTONE:
There is a sentence that you have in your book that you suggest that anybody who's writing to complain to their HMOs should include. Do you - do you happen to have that sentence in front of you or - [BOTH SPEAK AT ONCE]

> SHERNOFF:
Well yes, it's basically that you're reserving your right to sue them under state law. And I think that concerns most HMOs or most people that work for them because they may not be totally sure whether you are one of the excepted people that can sue and they may look at your claim a lot more carefully if they get a letter from you saying that you're not gonna take this decision laying down. You're gonna appeal to a higher court. You may even sue them.

You may consult a lawyer, you may consult the media. You're just not gonna take this laying down because this is too important to you. This is your health and this is your life. And you're paying premiums to these people for protection.

So when somebody like that comes along, that's a red flag to the HMO and they'll take a better look than somebody who just accepts their denial and goes away.

> GLADSTONE:
And if you can hint that you work for a state or government or public agency, whether or not you do, it might light a fire under them more.

> SHERNOFF:
Well it's - that's very possible.

> GLADSTONE:
Susan in Indiana writes: she said I've been arguing with Aetna since November 1998. The problems arose after my husband retired in June of 98. I work at the same place my husband did. I am now the primary spouse dependent.

Aetna failed to update our file and is now saying that they will not process any more submitted claims until the file is straightened out. In the meantime, I'm getting final notices on these bills. What do I do to light a fire under these people?

> SHERNOFF:
Boy I don't know. We just - we just had to take Aetna to court on a case where the jury found that the - Aetna was responsible for the death of a young man and stuck the widow with $750,000 worth of bills and we're still fighting them through the court system even though the jury came back with a whopping $120 million punitive damage verdict against them.

> GLADSTONE:
So they're just appealing and appealing and appealing.

> SHERNOFF:
Yes, they're appealing and appealing and appealing. So sometimes it's very very difficult to get their attention. And each, each case is, has to be judged on its own merits too. I mean it's hard - as a lawyer when people come to me with their problem - I really have to look at everything.

I have to look at what their health plan says. Are there really any exclusions that apply? Is the HMO acting reasonably or are they really off base? It takes a lot of study and analysis to really figure out who's right and who's wrong.

> GLADSTONE:
I'll say and that's actually something that you also spend some time on in your book. How do you read your own policy? I mean what do you do about unwritten clauses and exemptions and exceptions? What about deliberately obfuscatory language?

What should employees look for or ask about? How can they interpret or translate their own policy?

> SHERNOFF:
Well it's very very difficult. The law allows them to write these policies in strange and difficult language and complex language. About the best thing you can do, sometimes some of the HMOs put out handbooks which are supposedly like highlights -

- and written in, in more simple language. And it's certainly good to go over those because that's probably the easiest to understand. But you're absolutely correct. Sometimes these exclusions are buried in the master contract with the employer that you don't even see.

> GLADSTONE:
Well then what - can you offer maybe a set of questions that people ought to be asking themselves as they look over their - their policies?

> SHERNOFF:
Well yes. You can be asking - I would, if I were to join an HMO, I would want to know for example, do they allow the treating doctor's decisions on medical treatment to stand or do they have a procedure where the doctor can be overruled by somebody higher up in the HMO like some accountant type.

I would stay away from an HMO that allows that. I would also want to ask, do you give financial incentives to doctors or administrators to deny medical care?

> GLADSTONE:
And will the insurance company tell you whether they do or they don't?

> SHERNOFF:
Well they probably won't, but if you insist on getting the contract between them and the doctor, they - you might get it. I mean it is difficult. I would have to tell you that we, we get them because we've subpoenaed them once we sue them.

And we find out that they do indeed have these clauses where people get incentives to deny medical care. They may, they may tell you, they may not. A lot of states are passing laws which says they have to disclose everything.

> GLADSTONE:
Is that in the patients bill of rights?

> SHERNOFF:
Yes, it is. It prohibits that in the patients bill of rights. It prohibits financial incentives to deny medical care. So I would, I would want to know that. I would want to know how many specialists they have on their panel because if they have to go outside of their, their network, it's more expensive to them and they're reluctant to do it.

So if you have an HMO that has a wide variety of specialists in their network, that's better for you because then you're gonna probably get to a specialist a lot easier than if they have to go outside their network.

> GLADSTONE:
And is that information generally available?

> SHERNOFF:
That usually is available. They usually will tell you if they have a cardiologist or two cardiologists or do they have a specialist in neurology or do they have a specialist in, in oncology. They, they usually try to brag about that.

Like how many specialists they have. And so that's - that's probably one of the most easily received or gotten bits of information you could - you could get. And then you might try to find out if you can from the state department of insurance or corporations, how many complaints have been registered against this HMO in the last year.

And is their complaint ratio higher or lower than other HMOs. That you might be able to find out.

> GLADSTONE:
Charles in Los Angeles addresses a question or answers a question that you address in your book about coverage after leaving a job. He says I am a registered nurse and I used to work for Kaiser Permanente. I left the organization last November and now work for a smaller company in Monrovia.

In the 3 months that it took to qualify for benefits on the new job, Kaiser sent me a letter denying responsibility for any expenses incurred in getting treatment anywhere. I ended up not needing any medical care during that period but my question is, can they really legally deny me service unless I pay up front?

That's that weird space when you leave a job.

> SHERNOFF:
Well that is a real problem area because if you leave - if you leave a job, even if you're [ ? ] claims. The worst problem is if you get so hurt so bad or you get a serious ill - illness and you have to leave your job because your employer doesn't want to keep you on anymore because you're too sick to work -

- they can actually stop your claim by saying that the coverage is now gone because you're not working there anymore.

> GLADSTONE:
So the answer to Charles is yes, they can legally deny you service. Although I wonder whether the company that you work for can legally fire you if you become sick. [BOTH SPEAK AT ONCE]

> SHERNOFF:
Well they can - well yes, if you, if you're not, if you're not able to work anymore. But there is a provision called COBRA which is an acronym for another federal law which mandates that the employer has to offer you continuing coverage under COBRA when you leave employment for at least -

- usually it's around 18 months. But you have to pay the premium for it and the coverage is not as great as it was when you were working there.

> GLADSTONE:
Here's a question from Fyodor in Brooklyn. He says I am not a doctor and I don't work for an insurance company. I hate insurance companies but if the insurance companies felt pressured to approve every frivolous $100 prescription when a $20 generic would do just as well for fear of triggering a lawsuit if they didn't, wouldn't premiums go through the roof?

> SHERNOFF:
Well of course if they did that. If, if an insurance company felt pressured just to pay every, every claim the cost of - of healthcare would go up. We're not certainly advocating that. What we're advocating is that they certainly have the right to deny frivolous claims and frivolous procedures.

We're not talking about that. We're talking about legitimate claims that are recommendedby even their doctors. And then somebody upstairs denies it, based on cost. And somebody that's never even seen the patient.

> GLADSTONE:
Right that's - that's the problem.

> SHERNOFF:
That's the real problem. Not - not the - we would grant them the right to deny frivolous drugs, frivolous treatments that are not going to help anybody. We agree

> GLADSTONE:
I think I should read Cynthia's letter. Cynthia from Houston who sounds a lot like our Fyodor in Brooklyn. She says mine is not a question but a comment. I have worked at an HMO for several years now and the patients, while sometimes knowledgeable and willing to listen to reason, are for the most part, the worst patients I have ever seen.

They think because they pay $10 or in some cases $5, they can go to the doctor's office like they're going in to have a haircut. They walk in unannounced and demand to be seen. We are constantly fielding ridiculous requests all day long because they think HMO are their personal doctors on call.

Yes, sometimes there's a need for assertiveness but most of the time it is ridiculous. Someone should speak up for the doctors and their staff that have to put up with these people. HMO patients are among the worst I have ever seen.

I think she's - she probably has a good case here to be treated for stress related disorder. She sounds very sick of them.

> SHERNOFF:
Well I think this sounds to me like a person who works for an HMO and you can see her attitude. She doesn't like the patients at all. She's - she's definitely against by and large as a general proposition patients because she thinks they're -

- they're demanding, etc. etc. So here's somebody that works for an organization that's supposed to take care of people and she starts with a chip on her shoulder.

> GLADSTONE:
Well let's - maybe she didn't start that way. Maybe patients are wrong to consider their HMO doctors as their personal doctors on call. Maybe they are asking too much for the amount of money they pay.

> SHERNOFF:
But that's what a, that's what an HMO is. And if you look at the brochure that they put out, they entice people in there saying that we're gonna give you the best medical care. You're gonna get a doctor of your choosing. They're gonna take care of you.

That's the way it should be. In other words - most doctors that I have talked to are upset with HMOs themselves. They don't like the fact that they're overruled by bureaucrats and most of the doctor and doctor organizations are for the patients bill of rights.

> GLADSTONE:
But you will credit the - the notion that sometimes people are asking too much from their, from their health organization.

> SHERNOFF:
Well of course you always get in any system, some people who are demanding. I mean I - I'm a lawyer, I have a law firm. By and large my clients are - are nice people who have serious problems that need taking care of.

Once in a while, I get people who - whose personalities aren't the greatest and they are over demanding and overbearing, but that's usually a very small percentage.

> GLADSTONE:
Rene in Ashtabula says, ever since our changed their name from Blue Cross Blue Shield to Medical Mutual, we've had nothing but problems. Here's an example. My 6 year old son needed hearing aids, both ears. The family physician referred him to a specialist and that doctor wanted tests done to figure out why he lost his hearing.

An EKG, MRI, urine and blood work were all ordered. Two of the tests were done that day. Several weeks later we got a denial letter and a bill. Could you please tell me how we can be denied if there is an order from the doctor?

> SHERNOFF:
They - there you go, that's the typical case. I can't tell her. I don't understand that. I think it's illegal. If that person has the right to sue, I would say that they have a good case. I'm with that person. I don't understand it either.

> GLADSTONE:
Charles in New Hampshire writes, how can I be sure that I get the right tests that are needed? For example an MRI, which are expensive.

> SHERNOFF:
Right. And that's, that's what people worry about with the HMOs because if it's an expensive test or an expensive procedure, the HMOs are a little reluctant to - if - if it's a questionable call, whether the person should or should not get this test, they usually err on the side of not giving it because the HMO is a profit driven organization. Most of them are Wall Street insurance companies.

Owned - Aetna and others are all big big insurance companies. They make their money by denying medical care on the capitation system so if there's a benefit of the doubt to be given it's usually given to the HMO instead of the patient.

And that's why at the top, you talked about Helen Hunt and her remark, people are aware of the fact and they're outraged by the fact that for healthcare, that these close calls are being made in the name of profit and not in the name of patient care.

> GLADSTONE:
I haVe to say that the, the one thing that I found a bit disheartening about your book is that you offer long and exhaustive suggestions for what people can do to fight their HMO but in the end, there's no guarantee. In fact there's -

- there's not even all that much of an increased probability that you're going to get any satisfaction. What is the - what do you think are the chances that people can actually get what they need paid for, paid for?

> SHERNOFF:
Well that's a very good question. The - the book was written for 2 purposes. One is I did - I tried to give some practical advice in a very terrible system as to how to possibly maximize the chances of getting some results. And you're right, there's no guarantee.

I think the most important part of the book where there would be a guarantee is where I say we have to change the law so that we build in these guarantees and make it illegal for them to do the things that they're now doing. And that's why on page 89 I have a sample letter to a member of congress telling them to pass the bill that is now in front of congress to give people these guarantees that you're talking about.

And this is very serious. We could have these guarantees by the end of the year, including the right to sue. Now the HMO lobby and other strong lobbies are very much against it and they've been able to garner some political support with some who are -

- are more or less on the side of the HMOs in this issue.

> GLADSTONE:
But if the patients bill of rights is passed, won't that drive the cost of insurance and healthcare ever higher?

> SHERNOFF:
Well according to the study done by the congressional budget office which is used by both Democrats and Republicans - it is very credible, it will raise the premiums 1.3 percent which is really negligible. And for - for what it will guarantee, I think almost everybody in America would say golly, let's get that.

We can have all these guarantees that we really need and all these horrible stories will disappear -

> GLADSTONE:
I'm - I'm guessing that the HMO lobby has come up with a different figure.

> SHERNOFF:
Sure they have.

> GLADSTONE:
What's their figure?

> SHERNOFF:
Well they, they don't have any specific figure but their lobby says God, if you allow these lawsuits, all these lawyers are gonna be suing and there's gonna be a flood of litigation and the lawyers are gonna be rich and it's gonna increase the cost of healthcare tenfold.

They come up with all these wild accusations. They always do that. Every time you have something where you want to regulate the HMOs and make them pay what they're supposed to pay, they say it's gonna cost more. It's because they want to scare people away from it.

That's - that's been their public relations scheme for a hundred years.

> GLADSTONE:
We've got about 7 minutes left so I want to make sure we get to some more questions here. This is about a couple that has coverage and I know that you suggest in your book that if you have the option of having 2 insurance programs rather than just one, you should do it.

Roger in Michigan says I work for General Motors. They no longer pay the portion of the bill to the doctor that the other insurance - let me - well I'll take the question from the top. This is not so much a question about HMOs as it is about the coordination of benefits when 2 married people both have health insurance.

I work for General Motors. They no longer pay the portion of the bills to the doctor that the other insurance did not cover, even if the amount is less than what they would have covered if they were the only insurer. Have you followed that so far?

> SHERNOFF:
Well what he's talking about is coordination of benefits when you have two plans. One plan is usually primary and another is secondary and sometimes the secondary plan pays what, what the primary plan does not pay. So you - you end up with a lot more coverage when you have 2 people being -

- being a husband and wife working at different employers and having different coverages. So -

> GLADSTONE:
But wait a minute, let me finish Roger's letter because this is what's upsetting him. They also charged the amount that was paid by the other carrier against my annual benefit for dental as if they were the ones who paid it.

Thus reducing what I and my dependents were eligible for under their insurance. Is this legal?

> SHERNOFF:
Well that sounds wrong to me. I mean - but there's so many things that I see in my law practice that I think are wrong and that's why I - I battle insurance companies all the time on behalf of people like that because they do it.

And they assume that most people won't complain or do anything about it so they get away with it. And that's - that's been the nature of the game for so long with insurance - that that's why insurance companies I think have a fairly bad reputation.

Because they don't really seem to be interested in - in taking care of people's problems. Brooke, can I - am I allowed to mention where people can obtain this book?

> GLADSTONE:
As a matter of fact, what I'd like you to do is mention where they can obtain the book and also other places where they can find out information. In the back of the book you list a number of organizations and places they can go for information.

So mention where they can get your book and also some other sources.

> SHERNOFF:
Certainly. The book is Fight Back and Win. And you can order it through 1 800 All Book. That's A-l-l B-o-o-k. Or Amazon.com. Or your local bookstore.

> GLADSTONE:
I think we've gotten a clear idea of where to get your book. What about some other places to get information. [BOTH SPEAK AT ONCE]

> SHERNOFF:
All right. Some other places - there's a very good organization that fights for consumers out in California called Consumers for Quality Care. And they can be reached at phone numbers 310 392 0522.

> GLADSTONE:
Great, what about on the east coast?

> SHERNOFF:
On the east coast, there's a really good organization called Families USA, Washington DC. Phone number 202 628 3030.

> GLADSTONE:
That sounds great. Let me, let me get in a quick question about preexisting conditions. You devote quite a lot of time in your book to that. Candida in California says, I was with an HMO for 2 years on a group plan, then changed jobs.

I asked for a continuation of coverage from my HMO under individual coverage. I was denied for a condition that the HMO had covered for 2 years which is not a serious condition. Is this legal and if it isn't, what can I do about it?

> SHERNOFF:
Well, they used to be doing that a lot but congress did pass a law last year which did make it illegal for - at least in group policies for insurance companies to deny claims on preexisting conditions in certain circumstances.

So one has to check the most recent law on that. And then you really come down to, what's really a preexisting condition, because everybody has some sort of preexisting condition. And the question is, was it a condition that -

- that disabled you before or was diagnosed before? Because if it wasn't, then under the law it may not even be considered a preexisting condition at all.

> GLADSTONE:
Aren't HMOs changing for the better? Do you see any evidence of improvement and which HMO do you think has the best track record for handling customers complaints in a fair and effective way?

> SHERNOFF:
Well, from where I sit, I see people come to my office in droves and it's getting worse because - so I don't see any improvement at all. They don't seem to be motivated to improve. They seem to just be more interested in making money.

And we had a guy out in Los Angeles who burned himself up on the freeway, committed suicide after he put a big banner out on the freeway and stopped traffic for like 4 hours and the big banner said, HMOs are in it for - for the money.

And I think that's reflective of what, from that scene to the Hel - Helen Hunt line in that movie, to all the outrage that I'm seeing and hearing about -

> GLADSTONE:
And - and pressure from congress. Surely all of this kind of pressure is having some impact.

> SHERNOFF:
Oh, yeah. That's why we have the patient bill of rights up but - I just spent 2 days in Washington DC and - and people there are telling me that, that they're not getting enough letters and calls and faxes about the patient's bill of rights.

They think maybe the general public has maybe gone to sleep or they're in impeachment doubt or whatever the case may be people seem to not have the level of outrage that they did six months ago. So I'm hoping that the public will once again rise up and demand their rights.

> GLADSTONE:
Now I'm going to get back to you with one last really quick question and this is again from Rene in Ashtabula. You remember about the woman whose son had 2 hearing aids and there were a bunch of tests taken and the HMO denied pay - denied the tests -

- or denied paying for them after the doctor had ordered them.

> SHERNOFF:
Right.

> GLADSTONE:
And what she wants to know is, what measures can she take?

> SHERNOFF:
Well where does she live?

> GLADSTONE:
In Ashtabula. Where is Ashtabula? I don't know - [BOTH SPEAK AT ONCE]

> GLADSTONE:
I have no idea. [LAUGHS].

> SHERNOFF:
It may be a state that she can, she can either sue or - or threaten to sue or go to the department of insurance in that state or that's a good case to take to the media.

> GLADSTONE:
And probably one of these two organizations. Did you -

> SHERNOFF:
Yes.

> GLADSTONE:
- how about one organization in the south? Do you have one in the south?

> SHERNOFF:
Oh, let me see, I have, I have about 10 organizations as I recall listed. Let me see, south - there's a center for patient advocacy in McLean, Virginia and that phone number is 800 846 7444.

> GLADSTONE:
I think we're gonna have to stop there even though I know we could go on for another hour and a half. Thank you so much for being with us Mr. Shernoff.

> SHERNOFF:
You're welcome.

> GLADSTONE:
William Shernoff is a consumer attorney and author of Fight Back and Win, how to get your HMO to pay up. He joins us from a hotel in - hotel room in New York where he's on a book tour. Next week we'll discuss blending alternative medicine and conventional care.

Two doctors who set up a New York city hospital unit devoted to doing just that will join me here in our studios. That's Tuesday March 30th at our new time, 8 pm eastern, 5 Pacific, or 0100 GMT. Hope you can you join us then.

OnHealth Live netcast  transcripts are available within one week. OnHealth Live is produced in New York by John Keefe with research by Mary Esselman.

I'm Brooke Gladstone and thanks for listening.

HMOs Return