Most insurers also have the right to audit patient records for purposes that may include medical necessity. The problem with such reviews is that insurers and physicians have different objectives in their approaches to patient care, and one wonders to what extent financial motivation plays a part in determinations by insurers. Many physicians also feel that medical education should be the duty of medical schools and professional organizations, not HMOs . Referral is a time-consuming process that causes nightmares in physician offices. While it may be reasonable that patients see their primary care providers before seeking help from specialists, the complicated referral process serves no additional useful purpose except to discourage referrals by physicians.
Patients are often upset at the limited choices of in-plan specialists.
Worse still, patients are often referred to specialists not known to their primary care providers . There is also nothing more frustrating than having to call a managed care clerk for treatment pre-authorization, to get permission to prescribe a drug, or to have change medications because of formulary limitations. HMOs and insurers, however, are held to a different standard when they make medical decisions. Adverse outcome as a result of treatment delays or denials by insurers are, by law, the responsibility of the treating physicians and not of the insurers. This may be about to change.