-Caveat Lector- WJPBR Email News List [EMAIL PROTECTED] Peace at any cost is a Prelude to War! Patients fighting HMOs' denial of claims, and many are winning MICHELE CHANDLER [EMAIL PROTECTED] Dawn Ripley never had a problem with her health insurance plan -- until her daughter, Anna, came along last year. ``I noticed her head seemed misshapened, it seemed like she had more face on one side than the other,'' said Ripley, who lives in Weston. After several months of therapy, a physician determined that the infant's condition could be corrected with a special $3,000 helmet. Ripley's insurance company denied the request, deeming Anna's condition cosmetic, not medical. She paid out of pocket for the device. But Ripley also began a fight to the finish with her insurer -- which ultimately paid. Amid a national debate over patients' rights and growing frustration with managed care -- eight of every 10 Florida residents are in those plans -- thousands of Floridians each year are challenging the decisions of their HMOs, and many are winning. Statewide figures are not available, but at one healthcare insurer -- Health Options, one of the state's largest -- 4,981 Florida patients lodged complaints last year, and 675 entered the plan's formal grievance process. A patients' bill of rights that will be debated in Congress this week would give HMO members new rights to sue if they are denied needed care. The two proposals the Senate will debate differ mainly over how patients can sue managed-care companies and whether the companies' liability should be limited. But in many cases, there are existing alternatives. By state law, consumers at odds with an HMO's decision are entitled to appeal through their health plan's grievance process -- and thousands do just that every year. If the decision still doesn't go the patient's way, the consumer can take the case to the Statewide Provider and Subscriber Assistance Program, a state government-run panel of state officials, physicians and consumers that will make a binding decision. Overall, 21 percent of the 177 cases taken to the panel last year were decided in favor of patients, according to the Agency for Health Care Administration, which runs the program. An additional 29 percent of the cases were settled in favor of the consumer before the panel's review. The top disputes: repayment for emergency care, treatment by non-network medical providers, and clashes over benefits and what should be deemed medical necessities. Among the cases overturned by the state panel: It ordered an HMO to cover surgery needed by a patient who received facial injuries while cleaning his shotgun. The HMO had said it would not cover some of the surgery on the grounds that it was cosmetic; the HMO's doctors insisted the surgery was needed to restore function. Although Ripley's case was resolved without going before the state panel, Ripley's health plan also initially deemed Anna's condition cosmetic and would not pay for the head brace to correct it. That prompted Ripley to embark on a mission to prove that the device was a medically necessary treatment. She linked up with an Internet support group -- www.caps2000.org -- for families of children with the same problem. At night, she scoured medical encyclopedias online. She contacted the manufacturer of the head brace, who told her that her insurance company and others had paid for the device. She wrote to her elected officials. She got letters of support from the child's doctors. The health plan, which was offered by her husband John's employer, turned her down. She appealed a second time, as the health plan's grievance procedure allowed. And she contacted her husband's employer, United Parcel Service, hoping the company would help with her appeal. After several months, she won the appeal -- with the health plan agreeing the device was medically necessary. Payment for the device was approved a few weeks later and the Ripleys were reimbursed. The lesson? Persistence can pay off. ``That's how hard you have to fight them,'' Ripley said. ``Don't quit. Keep going.'' Beth Gabrini, an information specialist with the Florida Department of Elder Affairs' program known as SHINE, or Serving the Health Insurance Needs of Elders, said some denials stem from a simple error -- an improper billing code entered by a medical provider. Those codes are used by insurers to match a medical procedure with a payment. ``Usually the error might be made on the part of the doctor's office when they submitted your claim,'' Gabrini said. Call the physician's office, she said, and ask people there to make sure the code submitted is correct. ``They are pretty interested in getting their money, too, and they usually are pretty willing to see if an error has been made.'' If that's not the case, Florida HMOs are required by law to have a grievance process in place for patients who don't agree with their insurer's decision and want to appeal. And enlist your doctor's help. When appealing an insurance denial, your physician can be your most powerful ally, several consumer experts said. ``If the primary care physician and specialist are backing the patient, there's a 99 percent chance the case will be approved,'' said Gihan ElGindy, executive director of the Transcultural Educational Center, a health and education consulting firm in Virginia that assists people with insurance issues. The appeals process doesn't guarantee a win. In one case last year that went to the state panel, an HMO member with narcolepsy -- uncontrollable sleepiness -- requested a prescription medication not on the health plan's list of approved drugs. The health plan denied the request, a decision the statewide panel upheld. The panel also supported another HMO's decision not to pay for treatment by an out-of-network neurosurgeon for a health plan member with a brain tumor, saying the HMO network contained qualified medical specialists. Then there's Donna Young, 36, of Fort Lauderdale, who signed up for an HMO after she said a sales representative told her the health plan would cover the costly medication she needed for severe pain caused by multiple sclerosis. But the HMO did not cover the medication. Young filed a grievance, but the health plan denied the medication request. *COPYRIGHT NOTICE** In accordance with Title 17 U. S. C. 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