gws, It is like the two guys at the cash register after lunch, each trying to out fumble the other while pretending to try to beat the other getting out their wallet to pay for lunch. The more the HMO bean counters stall, the less they pay, in both the short run and long run, in their view. In the short run, debt service delayed is money earned. In being slow to pay they are essentialy getting interest free loans from all the folks they stall. In the long term they both reduce their immediate expenditure of goods and services AND train folks through Pavlovian conditioning to not ask for services. Of course I think this is counterproductive as it makes for more serious problems for many of those experiencing extended delays. Of course, I could be wrong and the bean counters might have compared the cost of the "few" worsened cases to the savings of stalling and chosen the best cost alternative, STALL. Isn't that what GM/Chevy did with their pickup fuel tank BOMBS? It was cheaper for them to stall and fight folks in court than to change the terribly stupid and dangerous design that placed gas tanks outboard of the frame where they would easily rupture in an accident.
A few years ago I dropped a concrete park bench seat on my foot while loading it into my truck. It only fell maybe 6-7 inches but broke my toe (wasn't wearing safety shoes). Like John Wayne in "The Longest Day" I just laced it up, TIGHT and went on. Later with my boot filling with blood and not being able to walk very good I was urged to go to the ER. As we were out of our HMO coverage area, I called the number on the member card and talked to some air head bozo who said sure thing go to the ER. Later my HMO said I didn't get authorization and should have driven 80 miles to an approved location. There are two numbers on the card and no explanation of which to call. By chance I got the WRONG one. I told them since it was my right foot I couldn't really drive so good and that irrespective of how superficial my injury and untreatable my broken toe (last bone on toe, they tape it to adjacent toe and that's it) was, I wasn't competent medical authority and couldn't make that determination without medical assistance. I didn't know how urgent my needs were and needed assistance in determining that. I needed the ER to tell me what I needed.____They paid.
Another time on vacation I stepped down from our Pickup camper (4X4 and pretty tall) onto an irregular street surface where the blacktop was really messed up and badly twisted my ankle. Went to medical service and got seen and left with an air splint on my ankle that permitted me to walk and drive. Another ration of static from my HMO but I "lettered" them into submision and they paid everything but the splint. Lots of folks would probably sue the city for the dangerous condition of the street but I just figure I should have looked where I was stepping. If I were scrambling up a slope in the sierras and twisted my ankle, who would I sue, the park service for not removing all possible hazards or maybe mother nature? "But its not nice to sue mother nature!!!!"
They try to win through attrition, wait you out, stall and delay. Stick to your guns. Write letters (return receipt requested) make your reasonable demands within the scope of your contract, and don't forget to ask things like "by when to expect a response, requested action, decision, or whatever." Make sure you put the ball firmly in their court. Make sure you make it clear what you expect and want to know by when to expect it. They, of course will resist your attempts to get them to make a promise, establish a schedule, or whatever but you still need to try.
Keep copies of all correspondence. Sometimes it helps to "jump the chain of command" and bypass lower echelon individuals and send copies of a "thread" of correspondence to higher level management to show the reasonable queries you make and the lack of timely beneficial response. Have you read the fine print? What is your ulltimate recourse? Have you signed away your rights to your day in court and must accept binding arbitration at the hands of an arbitrator (arbiTRAITOR - as in arbitrary and traitor) from an organization supported and selected by the HMO?
10% of the people make 90% of the noise. The squeaky wheel gets the grease. Don't be afraid to make some noise. I basically lay back and let just about everyone walk on me just a little (very little) but when it matters to me and I am being lied to, cheated, or like that, I can get pretty actively involved in nipping at the heels of the HMO or other dinosaur.
Patrick
