How to Navigate HMO Roadblocks and Dilemmas: A Clinician’s Guide

If you’re had a psychotherapy practice in the past ten years, then you realize how challenging working with HMOs can be. There are many common roadblocks that providers face such as getting reimbursed in a timely manner, limited authorizations with very few sessions allowed, provider audits, and even client/former client complaints to the HMO, to name a few.

Fortunately, there are resources available for the abovementioned roadblocks. The following includes resources and options in the event you are facing an HMO roadblock:

Direct Resolution: Contact the HMO/PPO directly. Determine what the dispute and appeals process requires in order to attempt a resolution directly.

Contact your Professional Organization: For example, the California Association of Marriage and Family Therapists (CAMFT) provides attorneys on staff available to answer clinician’s questions throughout the business day. Other organizations may have helpful resources that can increase clarity in order to make more informed decisions.

Quality Assurance: Many HMO companies have Quality Assurance or Quality Improvement Departments that may be able to assist you in your efforts to resolve the issue or dispute.

Formal Complaints: If you practice in California and believe that the HMO/PPO company has committed an offense that you have been unable to resolve with the insurance company itself, then you may contact to see if you are a candidate for launching a formal complaint. The phone number to this resource is 877-525-1295. Other states have similar resources that may be helpful to resolve the matter using a third-party.

Continuing Education: Seek out and receive relevant continuing education on the subject. There are CEU Providers who offer courses and/or course materials on how to successfully navigate through the difficulties of being a contracted or even uncontracted managed care provider.

Consult with Colleagues: It’s the age-old rule that you can never consult too much right? Consultation can help verify an already planned approach or offer new suggestions that are effective. Chances are that other clinicians can identify with your struggle.

Dealing with insurance companies presents a variety of challenges that no practitioner should have to face alone. Hopefully the resources provided here will assist you in navigating the sometimes complex HMO maze.