Excerpts from the Consumer Protection Healthcare Handbook

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The Consumer Protection Healthcare Handbook is a full length textbook (over 100 pages) based on Dr. A's education, training and experience. To get a feel for the contents of the handbook, you can view the Table of Contents and some excerpts. You may purchase the handbook Online using secure credit card transfer and download it electronically to your computer.

From Chapter 45, How To Make A Ton Of Money And Reform The Healthcare System.

There seems to be a new asertiveness with the Federal Government [...concerning...] poor quality medical care.

This is how it goes. If the HMO, the insurance company, the hospital or the doctor [... gave you ...] treatment that was SUBSTANDARD (is not quality medical care) then you can report them...

If [the Feds] find that the HMO, Doctor, Hospital or Insurance company (remember the insurance company can influence the way the doctors practice) has provided substandard care, ... the fines can be in the millions of dollars [and] and you are entitled to up to 1/3 of all this money. But you'll only get the money and teach them a needed lesson, if you know how to file the claim.

To file a claim, ...

This has got the HMOs, insurance companies, and hospital corporations extremely concerned. Just imagine all the times the hospitals, doctors, insurance companies, and HMOs have provided you or someone you love sub-standard care.

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It is a great way to make all of our citizens whistleblowers, to make money and to reform the bad HMOs, insurance companies, hospitals, and doctors.

From Chapter 4, What Is A Health Care Plan?

It is, pure and simple, a contract. No more and no less. You pay more in premiums, you get more in return (increased benefits, fewer restrictions, fewer exclusions, more choices).

In any contract one can get as much or as little as one wants (as benefits), and it is up to you, the consumer, to choose what you want to buy.

Like buying a home or a car, the more you pay the more you get and it is as simple as that.

You would be cautious of someone who promises to sell you a Cadillac for Volkswagen prices, right??---Then the same thing goes for any type of health care plan.

A health care contract/plan can have any type of exclusions such as heart attacks, seizures, medications, physical therapy, pre-natal care, immunizations, well baby care, strokes or abdominal surgery, etc. They can do this, though it would be dumb to buy this type of plan.

A health care contract can put as many limits as they want into their plan and it is not against the law (unless, in a particular state or federal program, there are any basic requirements of benefits). It is up to you the consumer to read the plan before you buy it, to know what it says, if it's a good plan and if they cover all that is necessary.

CONSUMER BEWARE!!!!!!!!!!

Don't read the plan after you buy it or when you need it, read it ahead of time!!!!!

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From Chapter 23, Bonus Plans

These are payment systems that reward physicians or nurses for giving you less medical care. Now, the HMOs claim this giving of bonuses to doctors and nurses is making them more COST-EFFECTIVE OR EFFICIENT. Just ask them when was the last time they ever gave a bonus to a doctor for early referral for an EXPENSIVE life saving treatment.

They do not have financial incentives or bonuses to encourage doctors to give quality care or to penalize them when they do not give enough care. Therefore the financial system is not balanced or safe when the bonuses are only based on lowering costs.

Let me tell you how it really works and then you can make up your own mind.

For example:

HOSPITALS:

In some hospitals they will give the nurse who is in charge of a medical floor or ward extra money each month or quarter if she or he goes under a fixed budget that the CEO sets up for him or her. So there are now financial incentives to spend less money on the care that the patients may need. This may occur when the head nurse assigns a high number of patients to each nurse or uses lower level (less qualified) nurses, such as nursing assistants or LVNs rather than the more qualified (and more expensive) RNs. So you may well wonder why there are now so few nurses per patient in the hospitals.

You might want to go and ask these head nurses or the CEOs of the Hospitals if they have this type of financial system set up.

REVIEWERS:

In utilization review organizations, HMOs or Insurance Companies will pay reviewers extra money at the end of the year by how much money the utilization review company is making. So they really do not have to say anything else to these review doctors or nurses, these reviewers automatically know that the more they cut costs by denying medical care that your doctor may be requesting, the greater the possibility for them to make more money at your expense.

GATEKEEPERS:

Many gatekeepers (which are usually your primary care doctors) make more money the more they deny emergency room visits, referrals to specialists, reduce the number of tests they order for you or the number of days [called length of stay (LOS)] they let you stay in the hospital.

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From Chapter 33, How To Fight The Health Care System For Your Rights!

Now this is where we start to put it all together. It is one thing to have all this good information I have given you and it is another to be able to put in into use. I am going to teach you how to do this. It is a legal and political game, but yet an important game. It is really not a game at all, it is standing up for your legal rights to have appropriate health care provided (that you have paid for).

I am not going to teach you how to manipulate the system to receive any health care you do not deserve. This is not the purpose of this handbook!!

In order to push for and expect that you will receive your health care rights you just cannot rely on the good intentions of your doctors, your hospital nor the payers (HMOs, Insurance Companies, Utilization Review Companies or the Government).

The only person you can rely on ultimately is yourself!!! You have to learn what to do and how to do it.

Also you must do everything in writing. Whoever you talk to, you must write down their first and last name, their title, the time and date you spoke to them. If they give you any assurances or decisions you must demand that they give it to you in writing. Without it in writing I am telling you it is completely worthless!!!!!!! I cannot tell you of all the horror stories I have heard where someone from the HMO or insurance company has assured either a doctor or a patient that they will or have approved something only later to lie and say they never approved it. Also, if they want to deny a medical request for treatment or payment, get that in writing. You must start creating a paper trail of what the payer is doing so that you can use it at a later time if it becomes necessary. In a court of law or with a certifying agency your word without documented evidence means absolutely nothing.

You have to know about the laws.

You have to know the rules of the certifying national organization rules.

You have to know what these payer organizations think, what they are worried about, their power, their weaknesses and when they are breaking the law.

You cannot allow them to tell you what your rights are or how they are going to approve or not approve your health care. You must tell them how your health care must be approved, certified, paid for etc. The minute you allow them to set the rules of the discussion is the minute you are dead meat.

TRUST NO ONE AND TAKE NO PRISONERS!!!!!!!

I want you to be fair and insist that they be fair.

I want everyone to be responsible, including you. You must also LEARN how to use the health care system appropriately. You have an obligation to work with your doctors and also the payers when they are doing it right and cooperate with them so you can receive good medical care.

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From Chapter 38, How To Receive Approval And Reimbursement For Emergency Room Care

First of all, if you think you have an emergency, call 911 immediately. Please do not wait for any type of pre-authorization, no matter what your HMO, Insurance Company or friends say.

There is a reason for the 911 number. It immediately puts you in touch with an Emergency Medical System (EMS) that has no financial gains in discouraging you not to seek emergency medical care.

I have colleagues who work in the emergency rooms who tell me that as emergency doctors they see horrible and tragic results when patients do not get to the nearest emergency room as soon as possible.

We (as doctors) know that you (as non-medical people) may think you have an emergency when in reality you do not. BUT that is not the point. The only one who really can determine if it is an emergency is a doctor who personally sees you.

If it is a true emergency (I'll define for you later what that means) then your insurance company or HMO will pay for it, if it is a covered benefit in your health care plan EVEN if you did not get pre-authorization ahead of time or did not go through their gatekeeper first.

The American College of Emergency Physicians, a very prominent medical organization that deals with and helps set standards regarding ACCESS to Emergency Medical Care, has a definition that you must use and the payers must use. It is called the 'Prudent Lay Persons' definition of an emergency medical condition. What my emergency room doctors friends tell me is that it is a very fair definition. It basically says, an emergency medical condition is where a reasonable non-medical person thinks they have a medical condition that, if not treated immediately in the emergency room, could result in serious harm or death to them.

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From Chapter 41, How To Choose A Physician?

Another difficult task. I have some good suggestions, but you really have to realize that even for me to judge a physician who practices a specialty that is different from mine is very, very difficult, and I am a doctor. You need to be honest with yourself that when you pick a doctor and you think the doctor is good you really do not know. What you are really saying to yourself is that you like this doctor. It is his or her bedside manner that you are responding to, because you really do not know if he or she is ordering the correct tests, making the correct decisions or prescribing the appropriate therapy.

There are some helpful hints that I can give you.

#1 Make sure the doctor is Board Certified. There is no excuse today for a doctor who is serious about his or her own field not to be Board Certified. This means that the Doctor has successfully completed a certified doctors training program and has taken a national test in his or her own field of medical expertise and has passed it. This goes also for general practitioners, that specialty now is called family practice and the doctors can take a national test for this to become board certified. Remember, no other test can even come close to the board exam test.

#2 Check out that book I told you about earlier called Questionable Doctors.

#3 Make sure that the doctor you have explains everything to you in a way you understand. If you do not understand what your medical problems are and why the doctor is doing something such as prescribing a medication, it is THE DOCTOR'S FAULT AND NOT YOURS!!! There is nothing in medicine that cannot be easily explained to a non-medical person if the doctor wants to take the time, has the communication skills to do it, cares enough, and knows what he or she is doing.

#4 Anything that is serious, you should always get a second opinion and if your doctor gets insulted or offended in any way, this is a red flag, a bad signal. Think about it, if the doctor is secure in him or herself and is a good, understanding person, this doctor should never get offended by this. I always suggest to my patients if they have any discomfort with my suggestions to get a second opinion.

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From Chapter 43, How To Choose A Lawyer?

Again very difficult, but I can give you some very helpful hints, which, if the attorney does not meet these, then stay away from them.

#1 Lawyers, like doctors, are specialized. So get a health care lawyer. Someone who specializes in health care. Health care is now very complicated and with all the new changes a general lawyer will have a lot of difficulty helping you.

#2 Get in writing from the attorney that he or she is a specialist in health care law.

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© Copyright 2006 Dr. Anonymous