Because Expericence Matters

HMO Lawsuits

A health maintenance organization, or HMO, covers all or most charges for care received within a defined network of providers; members must pay for care they receive outside the network. Should you need any assistance to clarify the coverage offered by your HMO in connection with a liability lawsuit, please contact us.

HMO coverage generally includes the following health care measures:

PREVENTION

Immunization: Immunization of children by age 2 against DPT, polio, measles/mumps/rubella, type B influenza, chicken pox, and hepatitis B.

Well-baby visits (first 15 months): Children receive six well-baby visits in first 15 months.

Well-child visits (ages 3-6): Children ages 3 to 6 receive at least one well-child visit per year.

Well-child visits (ages 12-21): Adolescents ages 12 to 21 receive at least one well-child visit every two years.

Prenatal care: Pregnant women receive prenatal care in the first trimester.

Post-delivery checkup: Pregnant women receive at least one post-delivery checkup 21 to 56 days after delivery.

Breast cancer screening: Women ages 52 and over receive at least one mammogram per year.

Cervical cancer screening: Women ages 21 and over receive at least one Pap smear per year.

Beta blocker after heart attack: Members are given beta blockers after a heart attack. Beta blockers are drugs that are known to reduce the risk of another heart attack.

Eye exam for diabetics: Diabetic members age 31 or over receive a retinal exam.

Mental illness follow-up: Members ages 6 and over who were hospitalized for mental illness receive follow-up care as outpatients after discharge.


ACCESS TO CARE (ADULTS)

Ages 20-44: Members ages 20 to 44 receive preventive or ambulatory health care (inpatient procedures, emergency room care, hospitalization, mental health care, and substance abuse care are generally subject to pre-approval).

Ages 45-64: As above, members ages 45 to 64.

Ages 65 and over: As above, members ages 65 and over.


ACCESS TO CARE (CHILDREN)

Ages 12-24 months: Children ages 12 to 24 months are seen by a primary-care provider at least once per year.

Ages 25 months-6 years: Children ages 25 months to 6 years are seen by a primary-care provider at least once per year.

Ages 7-11 years: Children ages 7 to 11 months are seen by a primary-care provider at least every two years.

Health maintenance organizations provide access to physicians with the necessary credentials in their respective fields:


PHYSICIAN'S CREDENTIALS

Primary-care providers: Primary-care physicians who are board certified in their specialty.

All specialists: Specialist physicians who are board certified in their specialty.

OB/GYN: OB/GYN specialists who are board certified in their specialty.

Pediatricians: Pediatricians who are board certified in their specialty.

Geriatricians: Geriatricians who are board certified in their specialty.


CONFLICTS OFTEN ARISE IN THE FOLLOWING CATEGORIES:

Availability of primary-care provider

Getting needed care: Members who say they have difficulty getting care that they or their physician considered necessary.

Referral to specialists: Members who have difficulty obtaining referrals to specialists.

Choice of physicians: Members who are dissatisfied with the range of doctors available.

Making appointments: Members who are dissatisfied about the length of time they had to wait between making an appointment for routine care and the day of the visit.

Medical malpractice or negligence on the part of the HMO and / or the physician is involved, when the above mentioned situations cause serious harm, injury or death to a patient.

Other factors include:


  • A disagreement over whether there is coverage for a loss, or a disagreement over the amount of coverage available.
  • Limiting the number of advanced types of radiology procedures, such as CAT scans and MRI's, or limiting biopsies.
  • Limiting referrals to specialists, or limiting the number of emergency room visits.
  • Abusive, unfair, or bad faith tactics used by the HMO.

The Miller Firm, LLC
The Sherman Building
108 Railroad Avenue
Orange, Virginia 22960
Toll free: 866-529-3323
Phone: 540-672-4224
Fax: 540-672-3055


Alexandria, VA Office
105 North Alfred Street
Alexandria, Virginia 22314
Toll Free: (800) 882-2525
Phone: (703) 519-8080
Fax: (703) 519-8084


Philadelphia Office
555 East City Avenue
Suite 910
Bala Cynwyd, PA 19004
Toll Free: (800) 689-6959
Phone: (610) 660-0622
Fax: (610) 660-0628