When you choose a PCP within
an HMO, first find out which specialists that PCP refers to.
Recently I made a most
remarkable discovery. When I entered the Medicare program, I had to choose a
doctor. I had just moved to a new town and knew nothing about the doctors there,
so I just picked one for my Primary Care Phyysician – PCP -- as a shot in the
dark. I figured that if I didn’t like him, I would just switch to someone else
in my HMO.
I was having second thoughts
about this doctor already when something erupted on my nose quite rapidly. I
showed it to my PCP and he said that it looked like a squamous cell skin cancer
and that it needed to be removed immediately. He gave me the name of one
dermatologist.
What? Only one? No choice at
all? I went through my HMO booklet and found a couple of dozen dermatologists
listed. In addition, I found a statement in there that I could self-refer
myself to a dermatologist five times a year. But I called the doctor given by
my PCP – whose appointment desk would only give me an appointment more than two
months away. Since this thing was rapidly growing, that was unwise to say the
least. I self-referred myself to another dermatology practice. Based on my
description they got me in within 24 hours and wanted to do a biopsy
immediately. However, I had found out more or less by accident that if I went
to any specialist outside my HMO network, or in my case subnetwork (huh?), if that doctor did anything I
was committing myself to pay for everything, not just the biopsy. So I had to
back off.
This is when I found out that
when I chose this PCP, without knowing it, I limited myself to specialists that
PCP was aligned with. I could not just use anyone in the Humana HMO manual I
had been sent.
This was completely
unacceptable to me, and I mounted a campaign to be allowed to see a
dermatologist within my HMO program but outside this secret network I had just
found out about. Through insistent phone calls, I finally got Humana to agree
to the outside referral; I was told that my PCP had to make the referral and that
then they would approve it. I had their commitment and a reference number to
the conversation. I had taken notes and read it back to them to make sure I had
it right.
So I called my PCP’s office
to get the referral. Instead, heir insurance specialist insisted that she had
to go through her Humana representative … who declared that the person
who authorized me to go to the dermatologist of my choice gave me “wrong”
information. She then went “up the chain of command” and got me an appointment
only one month away, still completely unacceptable. I think I got into a battle
of wills with a Humana employee who wasn’t about to honor a patient request
that bypassed her. If true, that says extremely negative things regarding the work
culture at Humana.
So I found a loophole in the
whole program that states that a member can change PCP’s to gain access to the
specialist of their choice (as long as that specialist is within the HMO, which
my choice was – I got them from my Humana manual).
So I changed PCP. His office
also got me in within 24 hours, and he has made a rush referral to the
dermatologist I went to and was so pleased with.
The biopsy should have been
done and read by now if the man at the first dermatologist’s appointment desk
had been reasonable. The biopsy would have been done already, and surgery either done or imminent. A battle of
wills with a bureaucrat at Humana helped prevent that. Interestingly, once the
first dermatology office called regarding the appointment my first PCP had set
up, I told them that it was much too far away for the circumstances, and that I
had changed PCP’s. They immediately mounted an aggressive campaign to get me as
a patient, suddenly declaring that they could see me “today or tomorrow,” and
calling both me and the old PCP office multiple times. I had to call them and
tell them in no uncertain terms to stop calling!
“Humana Gold Plus” sounds
really good, doesn’t it? I knew about the standard restrictions of an HMO. I
did not know that I had restricted myself to one dermatologist – and
probably one orthopedist for my knee injury that’s on hold until the skin
cancer is taken care of – and probably one opthomalogist for my cataracts. Etc.
Moreover, I am not at all satisfied that my old PCP was what any reasonable
person would call a “good” doctor, and I think he may have had only one
alignment with a dermatologist for that reason. It may well be that other
dermatologists did not choose to work with him. I don’t know, but I know that
even within an HMO, one is supposed to have more than one choice.
Humana, by the way, told me a
couple of things that simply weren’t true. When I spoke to one person, I
emphasized the urgency of having this skin cancer taken care of, and he snidely
commented that perhaps I should go to the emergency room. I called him on it
and told him that it was an inappropriate suggestion and that he knew it. He treated
me with respect after that (I was never at any time rude or abrupt with anyone
in this process, but I suspect he might have been trying to anger me so that he
would be justified in not considering what I was saying.)
Another Humana employee told
me that “most” doctors in Florida were in these invisible, secret subgroups. In
actuality, neither the dermatologist’s office nor my new PCP’s office knew what
I was talking about. I don’t know why my first PCP is networked like that, but
it’s highly restrictive – and both unacceptable and unnecessary.
Unfortunately one has to know
what questions to ask. Whether or not all the physicans in your HMO will be
available to you with the PCP you have chosen is an urgent question you should
ask before making a final PCP decision. Find out who that PCP refers to when
specialists are required. You don’t give up ALL choice by joining an HMO – or
shouldn’t, anyway.
I don’t appreciate that
Humana made me run such a maze and that I had to figure out the solution for
myself (what if I hadn’t been a good reader? What if I was still working and
didn’t have six hours or more a day to spend on the phone, reading my Humana
manual and researching online?) When Open Enrollment comes around in October,
Humana Gold Plus will have one less member.
