HMO Malpractice: What It Is and When to File a Claim

Health insurance is a complicated business in the US. It’s both a vital tool for keeping people healthy and a profoundly confusing maze of bureaucracy. With all the different plans, coverage levels, and conditions, it’s easy to get lost in the process and miss important details.

That’s how many HMOs get away with malpractice. HMO malpractice is an all-too-common issue in the US, with organizations taking advantage of patients’ confusion to avoid paying for covered conditions. Here’s what you need to know about HMO malpractice, what it looks like, and how to fight back if you think you’ve been hurt by your HMO.

What Is HMO Malpractice?

An HMO is a Health Maintenance Organization, sometimes called a managed care organization. These organizations are also known as “insurance companies” by most people. Insurance companies are supposed to cover the healthcare you need as determined by your insurance plan. However, they are also usually for-profit businesses with incentives to avoid paying for anything they don’t have to.

That’s why HMO malpractice is a thing. This type of malpractice occurs when the group delays or denies coverage for treatments you need. Specifically, it includes any act by your insurance comapny that leads to:

  • Missed or delayed diagnoses for reasonably obvious conditions
  • Delayed or denied care that causes your health to get worse
  • Delayed or denied medication that leaves your conditions untreated
  • Delayed or denied testing that prevents you from receiving a necessary diagnosis

Essentially, anything your insurance company does that prevents you from receiving the care you need is considered malpractice.

Examples of HMO Malpractice

HMO malpractice is all too common. There are many ways that your insurance company can delay or deny the treatment you need, such as:

Denial of Referral

Your regular primary care provider (PCP) isn’t an expert in every disease or condition. A fundamental part of the modern medical system is the referral of patients to experts when a condition exceeds the knowledge of a PCP.

However, HMO-paid PCPs are often incentivized to avoid costly referrals. This can lead to an HMO physician refusing to refer you to a specialist when you need specific treatment. If you don’t receive the referral you need, your condition can worsen and potentially become a chronic, life-long issue.

If this happens, it’s considered malpractice. The PCP is part of the company and responds to incentives from that organization. As a result, the organization is considered at least partially at fault.

Denial of Testing

Another common issue with these incentives is that they can prevent you from being tested for conditions at all. Many tests, such as mammograms, MRIs, and extensive bloodwork, are costly. HMOs often have strict standards regarding when these tests are covered to avoid excessive bills. However, if these standards are too severe, or if testing is denied despite it being covered, then the organization may prevent you from getting necessary testing done.

Many complex and debilitating conditions can’t be appropriately or officially diagnosed without tests. If you aren’t diagnosed with an illness because your insurance company will not approve appropriate tests, then you may have fallen victim to malpractice.

Ineffective Alternative Treatments

Sometimes, insurance companies won’t deny treatment. Instead, they’ll take the recommendation of your PCP and substitute another treatment that’s similar but less expensive. In some cases, this can work perfectly well, such as when the organization substitutes a generic medication instead of the identical brand-name drug.

Unfortunately, it doesn’t always work that well. Many potential substitutes have small but potentially critical differences that can cause significant harm to the wrong patient. For instance, substituting a different and less expensive antibiotic could cause patients with sulfa allergies life-threatening allergic reactions. This dangerous substitution is another form of malpractice.

How to File an HMO Malpractice Claim

Not every state permits you to sue HMO malpractice claims, but many do. The specific laws in each state vary, as do the agreements each organization offers to its customers. As such, holding your insurance company accountable for malpractice is complicated.

It’s still worthwhile, though. You can file a malpractice claim against your insurance company by following these steps.

Determine Your Cause of Action

Your claim needs a rock-solid complaint if it’s going to go anywhere. You need to meet three criteria to have an malpractice claim:

  • The organization denied or delayed treatment it should have covered
  • They acted in bad faith when denying or delaying that treatment
  • The lack of treatment harmed your health

If these three elements are present, you can move on to the next step.

Collect Evidence to Build Your Case

Now you need to gather evidence that your claim is accurate. This evidence should include documentation like:

  • Proof that you or your PCP requested specific treatment
  • Communication covering the denial or delay of treatment
  • Medical records demonstrating the harm you suffered

Your medical records, insurance claims, and bills are all valuable pieces of evidence. You can also save emails, letters, and other communication with your insurance company.

Work with a Qualified Attorney

Insurance companies have large legal departments dedicated to preventing lawsuits. Fighting them on your own is a recipe for failure. Instead, work with a qualified attorney to help you build your case and navigate the legal system. The right attorney makes all the difference when it comes to the success of your case.

Make Your HMO Do Its Job

Insurance companies don’t want to pay more than they have to for your care. Unfortunately, this can hurt you in real and long-lasting ways. If you’ve suffered because of HMO malpractice delaying or denying you necessary treatment, you’re not alone.

You can hold your HMO accountable for not doing its job, though. The first step is to consult with an experienced malpractice lawyer to discuss your case. The right lawyer will give you the information and help you need to fight back against an insurance company that’s not doing its job. Get started today by scheduling your consultation with the experts at the Law Offices of Michael Oran, APC.

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