Published 12:00 am Wednesday, November 8, 2000

LEE DRESSELHAUS / L’Observateur / November 8, 2000

So…here’s a scary thought. Besides Al Gore being president, or Hillarybeing in the Senate, that is.

I find it interesting that a clerk with a high school diploma (maybe) can decide whether or not a doctor, who has about a dozen years of profession-specific education behind him, has made the right decision about just what kind of treatment you may or may not need. Wait, let me back up a bit. I should have said behind him or her. Gotta remain politically correct. Thesethings are important to me, you know.

Anyway, you run that risk every day if you are unfortunate enough to have been dragooned by your employer into having to use an HMO as your insurance company. That’s right. Your doctor who, despite being overbearingand condescending when it comes to dealing with us normal mortals, and despite overbooking his packed waiting room (now THERE’S and appropriate term, waiting room) with patients, probably knows what they’re talking about when it comes to medical stuff. Usually anyway. We hope. So here’s a scenario. Say your doctor decides that you need a CAT scanbecause he or she suspects that part of your brain has ceased to function or has shriveled up and dried out, like a Hollywood celebrity, and they send you to get one. Now, this doctor has about a gazillion hours of education thatenables him or her to make that kind of decision. So off you go, secure in theknowledge that you are safely in the hands of that shining icon of our society, American Medicine. Sometime during this process you or youremployer or your doctor or whoever forwards the proper forms to your HMO, sometimes before but often after you’ve already had the CAT scan.

Then, in a blinding blast of completely ludicrous bureaucratic logic some slack-jawed gumby of a clerk whose only medical experience consists of a first aid course when he was a Cub Scout can review your paperwork and decide that, nope, you don’t need that.

Request denied.

Then guess what happens. You get the bill, baby. That’s right. The hospitalsystem, never known for it’s generosity, has to bill someone so, tag, you’re it. You have to pay for that five-dollar aspirin they gave you at the hospitalbecause you got a headache sitting in an packed waiting room that looked a little like the customs room at Ellis Island. You have to pay for the CAT scanwhich, of course, is a complicated and difficult procedure that takes all of 20 minutes and costs about a year’s salary. And when you get that bill in themail demanding a five-figure payment, your next child, and, oh, one of your toes, you gaze at it in utter disbelief because you just can’t believe your insurance company has denied your claim. And if you say to hell with this, I’mnot paying this, then the credit gremlins appear and the collection vultures start to gather.

Now, in the interest of fairness to HMO’s, there is an appeals process that can be followed if your claim has been denied. I’m not sure what in involvesbut I suspect that it just means that more than one gumby of a clerk takes a look at your case. The two- or three-gumby review system is probably a bitmore complicated and professional because the gumbys on that panel are probably better educated than the first gumby. They may have degrees inpolitical science or medieval history or something equally useful when it comes to deciding whether or not your doctor knew just what the hell he was talking about when he had the audacity to send you for further medical tests in the first place. And since it’s their job to save the HMO money at yourexpense the result of your pathetic appeal is often the same as the decision reached by gumby number one.

Request denied.

And if, by some fluke or through an ignorance of the multi-step procedures involved in utilizing your HMO’s services, you happen to slip outside their guidelines, you are lost. They absolutely will not pay if you violate anyprocedural issue. You must use the doctors they tell you to use, take themedications they tell you to take, and if the procedure calls for you to put your finger on your nose and turn around three times while shouting “Hail, Hillary!”, well, you’d better do it, because if you don’t, pal, they ain’t payin’.

Would someone please explain to me why we, as Americans, are so afraid of socialized medicine when we have a system of HMO’s shoved down our throats that is every bit as bad? I mean, if we’ve got to deal with a miserable health care system why not look at one who will treat everybody badly, and not just those with so-called insurance? Who came up with this whole HMO idea, anyway? And finally, one last, loosely-related thought. If you vote for Al Gore thiscoming Tuesday, see your doctor. You may need that CAT scan. I just hope you don’t have an HMO.

LEE DRESSELHAUS writes this column every Wednesday for L’Observateur.

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