An HMO client obtained a second opinion regarding a diagnosis of colon cancer. There was no authorization obtained for this second opinion from the client or primary care provider. What is the consequence of this action?
A) The client will be responsible for the entire bill for the second opinion.
B) The client will still receive full coverage.
C) The client will be dropped from the HMO for breaking the rules.
D) The client will be fined by the HMO for not using the authorization process.
A
Feedback:
Members of an HMO must receive authorization for secondary care, such as second opinions from specialists or diagnostic testing. If members obtain unauthorized care, they are responsible for the entire bill. In this way, HMOs serve as gatekeepers for healthcare services. The member will not be fined or dropped from the program but will not receive coverage for the service rendered from the second opinion.
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