Lawsuit Illustrates Issues Related to Securing Approval for Out-of-Network Care From HMOs
A lawsuit that claims Health Net refused to pay for an out-of-network specialist for a child with a rare disease "illustrates how the managed-care model of health care ... could make it difficult for patients who need specialized care," the Los Angeles Times reports.
Typically, HMO plans, which charge low premiums but limit which doctors a patient can see, require prior approval for coverage of out-of-network care. But Health Net's policy states that "in the event that treatment by a specialist is necessary, the member is entitled to a standing referral to that specialist."
In the case, a boy with metatrophic dysplasia, which causes the spine to twist when it grows, was referred to a specialist in Delaware. However, Health Net initially said there were experts in California who could treat the boy. Health Net denied the family's request for coverage of the specialist for 14 months, despite referrals to the Delaware-based specialist by the family's pediatrician and the head of children's orthopedics at the University of California-San Francisco.
Health Net on Tuesday said it learned local doctors could not treat the boy and granted the family's request for a referral (Vrana, Los Angeles Times, 11/9).