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American Morning

Interview with Lauren Young

Aired June 21, 2002 - 07:22   ET

THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.

THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.
DARYN KAGAN, CNN ANCHOR: Well, you can chalk one up for consumers this morning. In a battle with HMOs, the Supreme Court has ruled that states can require health plans to accept an outside second opinion when there's a dispute with a patient over paying for care.

The ruling came in the case of an Illinois woman. Her name is Debra Moran. She went to court after her HMO refused to pay for a $95,000 procedure to correct a nerve condition.

(BEGIN VIDEO CLIP)

DEBRA MORAN, PLAINTIFF: It's just been about, I guess, trying to teach the HMO a lesson, that they don't, they can't stomp all over the patients. They need to do what's medically necessary and they need to stop denying care just because they think that the people are going to go away.

(END VIDEO CLIP)

KAGAN: So what does this landmark decision mean for you and your health plan? And perhaps you have a fight plan in mind for you.

The current issue of "Smart Money" magazine is devoted to helping people stake their claim in the health care system. And senior writer Lauren Young we've dragged back here because you did such a good job talking about telemarketers earlier this week.

Talking about HMOs, so this goes all the way to the Supreme Court and most of the Justices said yes, you do have a right to a second opinion. So this is good news for millions of health care consumers out there.

LAUREN YOUNG, "SMART MONEY" MAGAZINE: It is. There's about 80 million people, 70 to 80 million depending on who you ask, who are enrolled in an HMO right now. You know, keep in mind that only 42 states have these actual review boards, and the number of reviews is very, very small. In Illinois, for example, in 2000, only 43 were requested.

KAGAN: Forty-three? So, that's shockingly low. But don't you think that's because people think they don't have a right to it? We've been so programmed. You're an HMO, you take what you get and you're just kind of stuck with it. YOUNG: I think you're absolutely right, Daryn. And in the broader picture, this is a huge victory for people who are patient advocates because, basically, with the Patient's Bill of Rights stalled in Congress, they really haven't made much progress. But here's the Supreme Court giving a nod and saying it's OK for the states to say that if somebody is denied surgery or treatment, that they can get the second opinion. So...

KAGAN: So there's a way to go. And actually there already, even before the Supreme Court decision, there already are resources out there. So let's talk about if you've been given a decision by your HMO that says no, you can't have that treatment or you can't go to that specialist, how do you go about fighting that decision?

YOUNG: OK, the first thing you want to do is put together a really good appeal packet. There are sample letters on a Web site called patientadvocate.org. And it's just a template for you to follow. So you really want to, you know, make your case very clearly, talk to your doctor and get a letter from them, as well, describing what your condition is. And finally, if you can do the research, go and get some medical journals that describe a treatment and kind of back up what you're trying to get to improve your health condition.

KAGAN: And that all goes into the packet?

YOUNG: It all goes into the packet.

KAGAN: Now, there might be help as close as your own company?

YOUNG: That's right. Your employee benefits manager, the next step is, you know, you do probably want to appeal and some HMOs let you do it up to five times. But a new law says that you should only do it twice. So you really want to climb the ladder and your employee benefits manager can help you, the state insurance board can help you. And in some cases, you can also go to professional claims specialists. There's a Web site called claims.org.

KAGAN: That was amazing to me. There's people in the business of helping you fight this fight.

YOUNG: Absolutely. You know, there's always people who can help you do anything in this world.

KAGAN: But when I was looking at that, though, I couldn't help but think, you know what? That's time. That takes time and that takes energy and if you're not feeling well or you have a medical problem, that might be the last thing that you have.

YOUNG: That's absolutely right. And actually I think you make a really good point, the reason why people don't go to a lawyer and take it outside, which is pretty much the last step, going to the review board and then to a lawyer, if you have to, is because it is very expensive and very time consuming and sometimes it's just not worth it.

But in Debra's case, you know, she... KAGAN: It sounded like she was angry and she was going to go fight it.

YOUNG: Right. She couldn't even lift a fork. That's how hard...

KAGAN: And yet they were saying no.

All right, let's go a step even before that. Perhaps you can avoid this problem by picking a plan at the beginning that's best suited for you and your family. And there's not just like, you just can't go to your friend and say who do you use and go to that person, because we're all in different situations.

How do you pick a good -- if you want to go with an HMO, how do you pick a good HMO for yourself?

YOUNG: Well, there is an excellent, excellent Web site that's put together by the managed care industry's watchdog group. It's called healthchoices.org and they evaluate every single plan, pretty much. Keep in mind, there's 500 HMOs.

KAGAN: It's overwhelming.

YOUNG: And that every state is different. So Aetna in New York might be different than Aetna in New Jersey.

KAGAN: OK, some of the things when you're looking at the different plans, look -- I mean is your doctor, because you're probably already going to a doctor or your kids are going to a pediatrician that you're happy with. So try to match that up so you don't have to change doctors?

YOUNG: That's the first question you're going to ask, is the doctor in my network, because if you're sick, you're not going to want to have to go and find somebody else to take care of you.

KAGAN: Right. And then what will actually be covered? Certain things are, certain things aren't.

YOUNG: Right. And, you know, if you travel a lot, for example, you want to make sure that if you are in an emergency room in Toronto that that's going to be covered.

KAGAN: And then one more tip. What will be my procedure to get care?

YOUNG: Right. Sometimes there's...

KAGAN: Co-pay and that kind of stuff?

YOUNG: Referrals, co-pay, a lot of times you need to get a referral to go see a specialist, so you want to ask about that.

KAGAN: Number one, I guess it sounds, do your homework and you're going to be helping yourself out the most. YOUNG: Right. You have to do a lot of homework, but it's definitely worth it in the end to be healthy.

KAGAN: Absolutely.

Lauren Young from "Smart Money," have a healthy weekend.

YOUNG: Yes.

KAGAN: Thanks for stopping by.

YOUNG: Thank you, Daryn.

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