Florida HMOs working on law to have all Medicaid patients belong to an HMO

[Danni R.]

No, it will not be good. And thank you for explaining, or illustrating, it for me with an example that I can grasp. I believe the biggest problem is that most people don't get the full picture. I am one of them. I have a hard time connecting the dots unless someone points them out. Again, this is NOT good. Perhaps, and hopefully there is a chance that this bill will not pass? Will it depend on how Florida votes during the next elections? What's your stab on this? And oh... if Mrs. Magoo had died, who would Mr. Magoo have to sue? It's crazy.

[Steve Verno]

The Sunday paper announced that Medicaid patients may be required to join an HMO, next year.  As a former Medicaid patient who joined a Florida HMO, it was a disaster and almost cost my wife her life. 

Anyone who has interacted with HMOs in Florida can tell you how HMOs do anything they can to not pay doctors.  The article said it requires passing a law to do this.  Getting a law passed should not be a problem.  The legislature is no doubt in the pocket of the HMOs as paid consultants or their spouse is paid to be a consultant.  If you are a Florida Senator who is paid $800,000 per year or your spouse is paid $800,000 per yeat by the HMOs, you will do nothing to stop your income. 

Lets say Dudley Dooright is a Medicaid patient and the law is passed which requires Dudley to join an HMO, so he joins ABC Medicaid HMO.  It is a 4th of July weekend and Dudley is sick.  His HMO requires Dudley to get permission to seek care out of the HMO network.  He calls at 2am and is told he has to wait until 6am before anyone comes into the HMO who can give approval.  he calls again at 6am and he is told he can wait until Tuesday morning, 3 days from now but if he goes out of network,he will be required to pay the claim himself.  Every hour he waits, Dudley becomes sicker, so he goes to see Dr. Strangelove, who is not part of the Medicaid HMO.  Three things may happen. 
1.  The claim, instead of being paid the $49 Medicaid fee, will be paid a $13.69 triage fee.  or 2.  The claim will be denied.  Dr. Strangelove is instructed it is a violation of Florida law to bill the Medicaid HMO parient. or 3.  The claim will be denied with instructions to bill Dudley.  Dudley refuses to pay and file a complaint against Dr Strangelove.  Dr. Strngelove gets a letter from the State Medicaid regulatory agency who directs him to cease billing Dudley and to write off the bill. 

In the end, Florida doctors no longer treat ABC HMO patients.  The appeal for the triage fee payment is denied.  Dr Strangelove can pay a lawyer to take ABC HMO to court.  ABC files motion after motion that Florida law has no allowance for court action.  They do this to make it financially impossible to win in court using a lawyer that wants $250 per hour and when the amount in question is about $26. Its cheaper to accept the $13.69 payment which is what the HMO knows will happen.  They can ignore all appeals or they can say the appeal was never received. No matter, the loser is the patient and the doctor.

The HMO wants the doctors to be contracted with them.  The contract has a payment clause to pay 20% of the Medicaid allowable.  If the doctor says no, the HMO (1)  sends the payment to the member.  If the doctor goes after the patient, the HMO says the doctor is violating Florida law by billing the patient or (2) the HMO pressures the hospital, where the doctor has privileges, to demand the doctor contract.  The HMO tells the hospital that they will be declared a non-par hospital and their patients are prohibited from seeking care at an out of network hospital. 

Being in Florida for almost 20 years, Ive seen every trick the HMOs can pull.  When I took my wife to the emergency room, I received a nasty letter from the HMO saying I will pay for the medical care myself if I did this again.  The day after I got the letter, I left the HMO. 

This will not be good for the Medicaid population.