September 23, 1999  Catastrophic Illness and Injuries: Challenging HMO Guidelines - Are Patients Powerful or Powerless?* Joseph L. Romano, Esquire The Law Offices of Joseph Romano  Objectives: The purpose of treatment guidelines will be discussed. Practical problems with treatment guidelines for TBI patients and healthcare providers will be reviewed, and weapons to defeat restrictive treatment guidelines will be highlighted. Treatment or Practice Guidelines: Recovery Recommendations or Treatment Barriers? What are treatment/practice guidelines? Purpose Pros and Cons Providing estimates of optimal recovery  Predicting complications a patient may experience Limits flexibility of treating professionals Examples of Restrictive Guidelines Unfair and unecessary medical documentation Overly restrictive guidelines: i.e. requesting unrealistic progress before acceptance into a TBI/coma stimulation/coma awareness program Problems with Treatment or Practice Guidelines for TBI The guidelines are published by health care management agencies, and vary from company to company The guidelines are written so they are open to HMO interpretation HMO guidelines are not provided to the insured, the insured's treating doctor or other health care professional Insurance companies modify the guidelines or restrict the guidelines according to their business needs Guidelines adopted by HMOs vary significantly from insurance plan to insurance plan Unsafe Practices in Managed Care Peer review Precertification and appellate process Roadblocks to deny or limit coverage Referal or no referal to a specialist in the HMO system/non-participating facilities Release of medical information: Are patients at Risk? Aggressive Managed Care Practices to Enforce Treatment or Practice Guidelines Appeals External reviews Bad Faith Suits and Legislation Integration of Special Education Benefits with Managed Care Insurance