Issued and entered November 22, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 6, 2002, Petitioner XXXXXXXXXXXX filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.

The issue involved is contractual in nature. There is no medical issue; therefore, review by an Independent Review Organization is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On October 30, 2002, the Office of Financial and Insurance Services (OFIS) received from Care Choices HMO (Care Choices) the information it used to make its final adverse determinations in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner is a Care Choices HMO subscriber who seeks authorization for a consultation with an out-of-network neurosurgeon. She suffers from lower back and lower left extremity pain and experiences significant pain from standing, walking, or driving for even short periods. She maintains full-time employment with restrictions on lifting, repetitive bending, twisting, crawling, or climbing. Her “in-network” back specialist recommends an evaluation by a neurosurgeon.

Petitioner requested authorization from Care Choices to go to an “out-of-network” neurosurgeon because the drive time is shorter compared to the drive time to the in-network neurosurgeon. Care Choices denied the authorization noting an in-network neurosurgeon was available. Petitioner filed an internal grievance with Care Choices, who issued its final adverse determination on October 1, 2002.

III
ISSUE

Whether Care Choices properly denied Petitioner authorization and coverage to see an out-of-network neurosurgeon for a surgical evaluation?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues Care Choices should cover services from an out-of-network neurosurgeon, because she cannot travel the greater distance to an in-network neurosurgeon without suffering significant pain. She stated she believes “…it is reasonable to see a surgeon out of network that is close to my house with less travel time. Driving short distances worsens my symptoms and pain.” Also, in a letter to Care Choices dated September 19, 2002, one of Petitioner’s treating physicians wrote “I do believe that this would be difficult for [Petitioner] to travel to and from [the in-network neurosurgeon] given her current symptoms and worsening pain with driving. For this reason, I feel that it is reasonable that she be referred to see a surgeon, which is closer to her home.”

CARE CHOICES ARGUMENT

In its Position Paper (submitted to OFIS on October 30, 2002) Care Choices argued:

Care Choices HMO has determined that the distance between Care Choices participating providers and the non par provider chosen by this member is equal and within reason.

• …member has chosen this provider…[Petitioner’s treating physician] did not recommend or refer this member to this provider.
• …MapQuest which does take into account road conditions and traffic when estimating driving time…clearly show[s] the distances to the providers to be within reasonable range. Most often, specialty care is available locally. Sometimes, the most appropriate provider is elsewhere.
• Care Choice members must coordinate all care through the [primary care physician] to approved participating specialists.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented by the parties. The focus of this analysis is whether Petitioner is eligible, under her Subscriber Certificate, to receive coverage for out-of-network services. Health maintenance organizations (HMOs), like Care Choices, operate within a network of medical providers who sign contracts with the HMO and charge the HMO a specially negotiated rate for various services and expenses. As a result, a fundamental premise of an HMO is to centralize health care delivery within the network of providers. If an HMO member uses an out-of-network provider, then payment for the services are greatly restricted or perhaps excluded.

In the case at hand, Petitioner’s Care Choices HMO Subscriber Certificate specifically conditions HMO coverage upon members receiving services within a network of participating providers. Section 5.2 of the Certificate states:

5.2 Covered Services-General
Requirements for Covered Services
Services covered by HMO must be:
(5) Provided by a HMO Participating Provider, except in emergencies.

This requirement in the Certificate is clear and it has very few exceptions. In emergencies, a non-participating provider may be used. Also, Michigan law requires HMOs to make providers available within a “reasonable distance” from their members, MCL 500.3531. In the case at hand, Petitioner did not require emergency treatment.

Moreover, the evidence submitted suggests the in-network provider is located within a reasonable distance from the Petitioner. Indeed, the MapQuest documents show the distances and driving times from Petitioner’s home to her chosen out-of-network provider and the closest in-network provider. These documents note Petitioner would have to travel an additional 4 to 19 minutes to go to an in-network neurosurgeon, rather than the out-of-network provider. The MapQuest information leads to the conclusion the in-network provider is within a reasonable distance from the Petitioner.

The Petitioner did not provide any conclusive or compelling evidence that the additional drive time to the in-network provider would cause her medical distress. Her argument appears to be based on factors of personal comfort, rather than medical need. While the Commissioner sympathizes with Petitioner and her significant back pain condition, the evidence does not warrant a finding of coverage for the non-participating provider in this matter. The Commissioner finds the Care Choices final adverse determination in this matter is valid.

V
ORDER

The Commissioner therefore upholds the Care Choices October 1, 2002, final adverse determination in this case. Care Choices is not required to cover the services of the out-of-network neurosurgeon.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.