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Friday July 30,2010

Navigating the World of Managed Care

by Risa Levovsky

Many caregivers do not know where to turn when they suspect that someone they know may be suffering from Alzheimer's disease or other forms of memory loss. In desperation, they look for an answer by reading books, surfing the Internet for information, and visiting numerous doctors who have varying opinions about the diagnosis of Alzheimer's disease. The search often leads to an improper diagnosis or just to a dead end.

There are many compassionate physicians who will be able to help you cope throughout his illness. As a caregiver, your physical and emotional needs must be taken into consideration every step of the way. If you have opted to join an HMO, Medicare HMO or Medicaid HMO, you are required to pick a primary care physician on the panel. Physicians have different amounts of experience in caring for older adults. Some lack the specialized skills and knowledge needed to diagnose and treat patients with Alzheimer's disease or other forms of memory loss. Although these plans are more economical than the Federal Medicare Program, you are restricted to seeing a physician on the panel.

A caregiver asks a very important question: My primary care provider has not offered to refer my husband to a geriatrician, neurologist, or geriatric psychiatrist. If we are members of an HMO, how do we obtain referrals for these specialists in our network?

Use your provider directory to choose a provider who meets your geographic and medical needs. Draft a letter making a formal written request for a referral to the specialist you have chosen from the panel. Send a copy of your request to your primary care provider and send a copy of the letter to the Medical Director of the HMO. His/her contact information should be listed in your provider directory or should be available to you by calling the HMO's customer service number.

A caregiver shares an important concern: I was able to get a referral from my primary care physician, but the receptionist at the specialist's office says the next available appointment is not for several weeks.

Once a referral is provided, it may take weeks or months before you can actually see the doctor. If this happens to you, you should not give up! Send a letter to the HMO's Medical Director. A letter of concern can be very powerful, especially if it gets to the leader of an organization. A sample letter is provided below:

Sample Letter

Date

Your address

Phone number

Name of HMO's Medical director

Address

Dear _________:

This letter is to formally notify you of my (concerns or dissatisfaction) with the length of time before accessing the urgent medical care needed by (person's name and social security or member #). (I, my husband, my wife etc) saw Dr. (primary care physician's name) __________ on (date) and he referred me to Dr. (specialists' name) _______, who is a specialist in your HMO. According to Dr.________'s receptionist, the first available appointment is not until (date). I am formally requesting your assistance in obtaining an immediate appointment with Dr. (specialists' name). Any delay in your assistance may result in severe medical and emotional implications. I look forward to hearing from you immediately regarding this matter. You may reach me at (Give home and/or work #'s along with your mailing address.) Thank you in advance for your cooperation.

Sincerely,

Cc: (The insurance commissioner in your state)