Plastic Surgery Interactive Resource

Why Wonít My Doctor Take the HMO?

By John Di Saia MD

This piece was originally written for the local press. It was published in
Sun Post News in February 11, 2003. It may be helpful for those trying to understand the
interface between the sub-specialist and managed (mangled?) care.

Many of you may have noticed that HMO insurance is not really popular in San Clemente. Many physicians simply donít take it. While your HMO would have you believe that this is a function of simple greed, the reasons for a physician (particularly a sub-specialist) to not deal with your HMO are multiple.

First are foremost, HMO systems pay poorly. When Medicare was first enacted many physicians would not accept it. Many HMO plans pay well under Medicare rates. Medicine is unfortunately a business. When your doctor is paid below overhead, either he stops it or goes out of business. My past dealings with HMOs lead me to choose the former option.

Another major issue with which physicians can have trouble with their local HMO is the pre-approval process. When your surgeon wants to operate for you, he must go through a pre-approval process. Not only does this delay your care, but it makes it more expensive for the doctor to provide it. A member of the doctorís office staff gets the wonderful duty of calling or faxing a form to the HMO requesting approval for the procedure. Your "gatekeeper" for the HMO must answer this and provide approval if it is deemed appropriate. Additional follow-up phone calls are also frequently required. Even if the procedure is approved, almost invariably at the bottom of the approval letter is:

"This does not guarantee payment."

So even after the doctor (and the patient) have waited sometimes weeks to proceed (assuming the procedure is approved), the insurance company may eventually refuse to pay for it. Pre-approval indicates that the doctor can then attempt to bill the procedure. Thatís all. So after your surgery another member of the office staff assembles a bill to mail your insurer. Not infrequently, this step needs to be repeated as the HMO tends to lose bills. Where do they put them? Sometimes payment can take over a year. Usually it is 1-3 months. Try to think of another business in which payment for a service takes months on average to arrive.

On greed, it is laughable that insurance company personnel have the nerve to call doctors greedy! A simple search on the internet reveals data on health care CEO reimbursement. The listing I found was for the year 1999. The chairman of Cigna that year was on a salary of $1,173,100. He also got a bonus of 4,000,000! Aetna and PacifiCare were also included on the list of CEOs with nearly two million dollars in compensation each for the year!

Physicians have frequently made significant sacrifices and incurred debt to tolerate training that spans a decade. To be told that I make too much money by companies paying their chief executives in one year more than Iíll make in ten is intolerable! Worse yet, for these companies to deny necessary medical treatment in the face of significant profits is criminal. The fact that the law at present doesnít see it that way is even worse.

John Di Saia MD is a board certified Plastic and Reconstructive Surgeon practicing in Orange County California. He can be found online via his web site at: or via his office at (949) 369-5932.


Note: This piece is written for the general information of those seeking Plastic Surgery. It is presented freely in this format for this purpose. No other rights are granted. It has as a matter of fact already been printed in Sun Post News in the Feb 11 2003 issue. It may not be duplicated, cited or otherwise copied in any form without the written consent of the author and magazine.