How HMOs Delay Access to Care

Health Maintenance Organizations (HMOs) were originally promoted as a way to control healthcare costs while coordinating patient care. In practice, however, many HMO subscribers experience significant delays in receiving medically necessary treatment. These delays are not accidental. They are often built into the structure of the HMO model itself, where cost containment, administrative complexity, and divided responsibility can override a patient’s best interests.

For patients, the result is often the same: weeks or months of waiting, cancelled procedures, worsening medical conditions, and mounting frustration, while insurers and medical groups deflect blame. If your access to necessary medical treatment was delayed or denied by your HMO, call Gianell & Morris in Los Angeles to speak with a skilled and experienced California health insurance denial attorney.

The “Gatekeeper” System as a Barrier to Care

One of the defining features of an HMO is the gatekeeper requirement. Patients must typically start with a primary care physician (PCP) before they can see a specialist, obtain diagnostic testing, or receive advanced treatment. In theory, this promotes coordinated care. In reality, it often creates bottlenecks.

Patients may wait weeks just to see their PCP, only to be told that a referral request must be submitted for approval. That referral can then sit in administrative review, be sent back for clarification, or be denied outright. If the referral is approved, the patient may face additional delays trying to schedule with an in-network specialist who is actually available.

At every step, the patient’s care is dependent not on medical urgency but on process, and each layer of process introduces delay.

Capitation and the Conflict Between Cost and Care

HMOs commonly operate under capitation payment models, where medical groups are paid a fixed amount per patient, regardless of how much care that patient actually needs. While this model is designed to incentivize efficiency, it can also create a powerful financial disincentive to provide expensive or specialized care.

Under capitation, referrals, imaging, surgeries, and hospitalizations are costs that reduce a medical group’s margins. As a result, patients may encounter resistance to referrals, repeated requests for “conservative treatment,” or pressure to delay or avoid more advanced care, even when their condition clearly warrants it.

This financial structure can cause a patient’s best interests to get lost. Decisions that should be driven by medical necessity are instead influenced by budgetary considerations that the patient never agreed to and cannot see.

Finger-Pointing Between Insurers and Medical Groups

One of the most frustrating aspects of HMO delays is the way responsibility is fragmented. When care is delayed or denied, the insurance company may claim that the decision rests with the medical group. The medical group, in turn, may blame the insurer’s authorization rules, network limitations, or reimbursement policies.

Meanwhile, the patient is left in limbo, caught between two entities that each deny responsibility while their medical condition worsens. Calls go unanswered. Messages are redirected. Appeals are bounced back and forth.

From a legal and regulatory perspective, this finger-pointing does not absolve either party of responsibility. But from the patient’s perspective, it often feels impossible to know who is actually in control of their care or how to force action.

Surgeries and Procedures Cancelled at the Last Minute

Another disturbing way HMOs delay care is through last-minute cancellations of surgeries or procedures. Patients may complete pre-operative testing, arrange time off work, and prepare physically and emotionally for surgery, only to be told days or even hours beforehand that authorization has been withdrawn or never properly issued.

These cancellations are often blamed on “administrative errors,” missing paperwork, or disputes over coverage responsibility. But for patients, the impact is profound. Pain continues. Recovery is postponed. In some cases, conditions worsen, making eventual treatment riskier and more complex.

Last-minute cancellations are particularly troubling because they suggest a breakdown in coordination and oversight, yet patients bear the full cost of that breakdown.

Delays That Function as Silent Denials

HMOs do not always deny care outright. Instead, they may delay so long that the denial becomes implicit. Authorization requests go unanswered. Referrals are approved, but appointments are unavailable for months. Providers are technically “in network” but not accepting new patients.

These delays can be just as harmful as explicit denials. A delay in cancer treatment, surgery, or mental health care can permanently affect outcomes. And because there is no formal denial letter, patients may not even realize their rights are being violated or that appeal deadlines are approaching.

In many cases, delay is a strategy that allows HMOs to avoid scrutiny while still limiting utilization.

The Legal Standards HMOs Are Supposed to Follow

California law requires HMOs to provide timely access to care, ensure adequate provider networks, and act in good faith when making coverage decisions. Delays caused by administrative dysfunction, financial incentives, or poor coordination can violate these obligations.

Importantly, HMOs cannot evade responsibility simply by delegating care decisions to medical groups. When systemic delays harm patients, both insurers and delegated entities may be accountable.

However, proving these violations requires careful documentation, medical evidence, and a deep understanding of how HMOs operate behind the scenes.

Why These Cases Are So Difficult to Challenge Alone

HMO delay cases are rarely straightforward. They involve overlapping contracts, opaque financial arrangements, and complex regulatory frameworks. Insurers and medical groups are sophisticated entities with teams of administrators and attorneys.

Patients, by contrast, are often sick, overwhelmed, and unfamiliar with the legal standards that protect them. Without experienced legal guidance, delays can continue unchecked, and opportunities to challenge unlawful conduct may be missed.

How Gianelli & Morris Helps Patients Navigate HMO Delays

At Gianelli & Morris, we represent California patients whose access to care has been unreasonably delayed or denied by HMOs. We understand how gatekeeper systems, capitation models, and delegated risk arrangements operate and how they can be misused to the detriment of patients.

We help clients identify when delays cross the legal line, pursue appeals and grievances, and take action when insurers or medical groups act in bad faith. We represent clients statewide, including in Los Angeles, San Diego, San Francisco, Sacramento, San Jose, Oakland, and throughout California.

If your HMO has delayed your care, cancelled your procedure, or left you stuck between an insurer and a medical group while your health suffers, you may have options.

Healthcare should not be a waiting game. When HMO practices put profits and process ahead of patients, legal accountability may be the only way to restore access to care. Contact Gianelli & Morris to learn how we can help.