The front page of The Washington Post of March 11, 1998, contained a story purporting to illustrate the battle which doctors, hospitals and other health care providers face in getting insurers to pay legitimate health care claims. The story is well worth further analytical study.

"{A woman} fell off a 40-foot cliff in the Shenandoah Mountains while hiking in the summer of 1996 and was taken by helicopter to a Virginia hospital with fractures of her skull, arm and pelvis. Her HMO (Health Maintenance Organization) refused to pay the hospital, saying it failed to obtain 'pre-authorization.'

"More than a year later, after the hospital sued her for $10,238.08, she sought help from the Maryland Insurance Administration. {The HMO} partly relented in January , agreeing to pay $5,353 of emergency room and air ambulance charges.

"But Maryland Insurance Commissioner Steven B. Larsen said that wasn't good enough. Last week, he fined the HMO $1,000 and ordered it to pay the entire bill."

Why are you laughing? You're delighted that the villain got its "come-uppance," aren't you? Before we tag the hapless insurance company with that label, however, let us have a closer look at just what it is that the HMO is asking. It only seeks notification, before the fact, that a subscriber is about to use its services. In this case, it is undisputed that the hiker had some time between the beginning of the fall and its termination and it is only necessary to determine whether that time was sufficient to give the required notice. That, in turn, depends upon (1) the weight of the falling subscriber, (2) the speed with which she fell, (3) the direction of fall, (4) the humidity, and

(5) whether ordinary prudence would have dictated that she carry an umbrella for use as a parachute.

Applying the standard formula, we see that :

The result makes it perfectly clear that had the hiker, on the way down, used her cellular phone to call her HMO for pre-authorization instead of yelling "Help! Help!", the necessary permission could easily have been obtained in timely fashion. Oh, yes-her HMO would know that she carries a cellular phone with her at all times and she could not, therefore, plead that she lacked the means to communicate with her HMO.

Is it unreasonable to expect a subscriber to anticipate a fall when hovering on the edge of a 40-foot cliff? Had she exercised common foresight, she would have had ample time to notify her HMO even before her fall. Think what a sorry mess would be created if every subscriber fell off of a cliff without permission! The blame for not having the requisite authorization lies squarely with the irresponsible subscriber whose callous disregard of the rules makes it more difficult for those who properly plan their accidents. Furthermore, why should an HMO lose profits simply because its subscribers prefer to do things their own way rather than to follow the rules which are intended to maximize revenues? After all, an HMO is not a charitable organization.

It seems obvious that no thought has been given by the regulatory agencies as to how an HMO can make money if it cannot arbitrarily refuse to pay for necessary services. This business about caring for those who cannot pay their own way is nonsense. After all, what does the community do for the HMOs?

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