PACIFICARE: Okla. Medicare HMO Reverses 43% of Denials
Winning the dubious distinction of having the highest rate of overturned care or payment denial decisions in the nation, PacifiCare of Oklahoma has been ordered to pay for services in 43% of its Oklahoma City-area Medicare HMO denials last year, the Tulsa World reports. PacifiCare's Secure Horizons Medicare HMO in Tulsa fared better, with HCFA regulators demanding reversal of just 13.5% of its care denials. Three other Oklahoma Medicare HMOs had very few or no denials reversed. PacifiCare, whose Oklahoma City HMO was ordered to reverse 9 of 21 care denial decisions, attributed its high rate to a "lack of understanding of emergency room admission standards by some of its contracted physicians" who, motivated to minimize costs, denied emergency care to members who visited a non-affiliated hospital or whose condition did not, they felt, warrant emergency treatment. Dr. Steve Sanders, PacifiCare of Oklahoma's medical director, said the insurer is "working with Oklahoma City providers and expects to erase unwarranted denial-of-care decisions" (Gearon, 5/26).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.