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Using a strategy to keep down HMO's premiums and provider costs, HMO's contract with Individual Independent Practitioners; especially specialists. Last year I happened to be sitting in a local doctors office while three representatives from major insurance companies were waiting to meet with the doctor. The physician is a specialist and expert in his field.

The three insurance representatives were from Blue Cross/Blue Shield, Harvard Pilgrim Community Health and Tufts Health Care. I quietly listened as I heard the insurance representatives discuss how they were going to help the doctors bring down his costs to their insurance carriers.

All the insurance carriers wanted the doctor/ specialist to do a certain number of operations a day in order to met the insurance carriers requirements. The resultant effect, was the doctor decided not to sign contracts with any of the HMO's because he felt it comprised patient care.

Another defensive tactic used by doctors is to protect the quality of the services which they offer to their patients is to operate Walk In Clinics where they only accept cash. This allows the doctor to provide the highest quality of care for a reasonable price. We found many patients who used these type of doctors had private insurance which only reimbursed a small percentage of the actual doctors fee or HMO's they chose not to use.

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Another instance of HMO trying to control the delivery of medical care can be found in New York City. Oxford Health Plan has been known to harass doctors as a means of holding up money owing and due the contracted physicians. This is a form of cost containment. Instead of abusing the provider the insurance companies now abuse the physicians. In the New York Times, on January 11, 1998, Ian Fisher wrote; "Critics say that managed care in the New York area is essentially discounted fee-for-service medicine, and that such an approach was a major reason for the financial problems of the largest HMO in New York, Oxford Health Plans. "

"Managed care companies do not manage care," said Kenneth E. Raske, president of the Greater New York Hospital Association, a trade group. "Instead they manage price, the prices they pay to providers. There are really few good examples of any sound managed care in New York." Many people in the managed care industry contend that new laws and regulations are forcing the industry to make changes that drive up costs: specifically, regulations like the Managed Care Bill of Rights in New York, which requires health maintenance organizations to disclose certain information to consumers, and laws around the region mandating minimum hospital stays for procedures like births and mastectomies."

HMO's have decided that if they can eliminate the costs involved with providing high quality specialized care; they can reduce their overall costs with a minimum of doctor opposition. By buying or attacking private practices external standards for quality care no longer exist.

Doctors providing fertility care to patients are the constant target of insurance companies. In these cases, the insurance company first makes an agreement with the doctor. Then they wait to collect a certain amount of documentation and records at which point they accuse the doctor and/or his practice of fraud or improper billing.

Since most doctors cannot afford the bad publicity they go out of business by the time the insurance company has completed their audit and found the doctor and/or his practice did not do anything wrong. By reducing the number of independent practices, insurance companies continue their practice of patient and physican abuse.

These types of illegal tactics guarantee that our patient care will be minimized by greedy insurance carriers. To help keep American medicine safe for you; email your Senator using the sidebar on this page.

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