Richard L. Bruno is chairperson of the International Post-Polio Task Force and director of The Post-Polio Institute at Englewood Hospital and Medical Center. Please e-mail questions directly to him at ppsforum@newmobility.com.

Note: This column is for information purposes only and is not intended as a substitute for professional medical advice.

Q: My medical coverage has changed and the new HMO won't allow me to see my doctor, a well-known polio specialist, who is not in the HMO network. The new HMO says their "in-network" doctors are PPS specialists. I have called each of them and not one has ever treated a polio survivor. Is there anything I can do to get the care I need?

A: You bet there is! But first you must know what your HMO benefits are. Do you have an out-of-network benefit that allows you to see specialists--physicians, psychotherapists, physical and occupational therapists--if in-network providers don't know about PPS? Do your benefits allow you have durable medial equipment like braces and wheelchairs? If your HMO denies these benefits, here's how to get what you need.

When you call to appeal a denial, get the name, phone and fax number of the "provider service representative" you talk to. Ask for that person when you call back or ask to be assigned a case manager so you can develop a relationship with one person and not have to tell your story over and over. Have your HMO benefits book handy so you can refer to it. Keep notes of the date, time and what the person says, especially if you're told "Yes" one day and "No" the next. This type of contradiction supports the case that the HMO is trying not to fulfill the terms of its contract.

If you don't hear from the representative in two days, or he says "No" to your request, call his supervisor. But get the name, phone and fax number of the HMO's medical director and president first. If you don't get satisfaction from the supervisor say, "If you won't help me I will call Mr. Jones, president of the HMO." If you still don't get satisfaction, call the director of provider services, then the medical director and, finally, the president of the HMO. You should also ask your primary care physician (PCP) to call and to fax letters on your behalf.

Don't wait more than a few days between each higher person you call. The HMOs want to delay as long as possible. Before you talk to the medical director or president's office, get the name of your state's insurance commissioner and attorney general. When you call, mention all the people you've talked to, what they said and how they said it, and any contradictory information you've received. Say that you believe the HMO is intentionally refusing to provide benefits and that your next step is a formal complaint to the insurance commissioner and attorney general, especially if you received an authorization number for a service and the HMO refuses to pay the bill.

The phrases "intentional deception" and "insurance fraud" make HMOs listen up, especially if you had an authorization number for a service and the HMO now refuses to pay the bill. Some HMOs have a policy to send you to out-of-network specialists, and pay at in-network rates, if there are no PPS specialists in-network or within 60 minutes or 30 miles of your home. But you have to show that any in-network specialists are not PPS smart. Call the specialists and ask The Three Questions: 1) How many polio survivors have you treated; 2) How many PPS patients have you evaluated; 3) How many patients have you treated for PPS? If the answer to Question 3 is less than 12, the provider is not a PPS specialist.

If the providers won't talk to you or refuses to answer The Three Questions, tell the HMO. Some states, like New Jersey, have HMO laws that require out-of-network specialist referrals and allow only a medical doctor to deny services. Call the insurance commissioner to see if your state has such a law. If it doesn't, there's a new arrow in your quiver. In March 2001, a U.S. Administrative Law Judge found that an HMO wrongfully denied a polio survivor expert care for her PPS and ruled that the HMO must pay for her out-of-network treatment by PPS. This ruling doesn't force HMOs in every state to provide expert care for PPS. But you can send the ruling to your HMO if you're denied treatment because it shows that judges are stopping HMOs from sending polio survivors to in-network doctors or therapists who have no experience with PPS.

The bad press this case is getting in Connecticut may scare HMOs into doing the right thing. And going to the press is always your final threat and last resort. How much will any HMO like seeing you and all your polio survivor friends in front of their corporate headquarters--braces, crutches, wheelchairs and all--on the evening news? HMOs want you to spend hours going round and round on the phone and to give up. But don't give up! You can wear HMOs down and get what you need if you know your rights and work your way up their corporate ladder.