SOME CUSTOMERS ENSNARED BY CONFUSING HMO REQUIREMENTS.

Byline: Carol Marie Cropper The New York Times

So you're thinking of joining an HMO, and your selection of doctors is all-important. You look at the health maintenance organization's list and there, plain as day, is the pediatrician who has been treating Junior since he was a baby. And there, among the specialists, is the orthopedist who fixed your bad knee. Your wife's gynecologist is listed, too.

No problem, you say.

But wait. Before you join, there are a few questions you should ask, said Geraldine Dallek of Families USA, a health care advocacy group in Washington.

One of the most basic is: ``Can I actually see all these doctors?'' The answer, unfortunately, is often no.

For various reasons, patients can find themselves stuck for a year in an HMO with none of the doctors they wanted. The list, for example, may have been outdated, or maybe a doctor was dismissed right after the annual sign-up period for new members.

One California HMO, Foundation Health, had problems a few years ago after it ran a sprawling advertisement in The Sacramento Bee boasting of all the doctors it offered.

The trouble was, some of those doctors were dead. Others worked for competing HMOs. After physicians complained, Foundation agreed to pay a $75,000 civil penalty and it ran another ad, this time under the headline, ``We Goofed.'' A spokesman said the HMO had simply run the wrong list by mistake.

Connie Barron, a lobbyist with the Texas Medical Association, tells of a San Antonio patient who joined an HMO because his child's pediatrician was on the list, only to find that the doctor had not been in the organization for months.

Barron said she called the HMO and was told: ``Oh, gee, we already had those provider lists out there. We can't possibly change our provider lists every time we have a change. It's just too expensive.''

The bottom line, she said: ``If you see a doctor's name on the list, don't assume that that's current.''

Perhaps the trickiest problem for a patient is understanding that just because doctors or hospitals are covered by an HMO doesn't always mean he can go to them, Dallek said.

Some employers who self-insure offer what is called a limited-provider network. They buy access to a handful of the HMO's doctors, not the full list. Their employees must limit themselves to the smaller list, which saves the companies money.

Even more common are HMOs that are subdivided into different medical groups, sometimes based on where the patient lives. For example, two people working side by side in New York might see the same doctors listed in their health plan brochures. But if one of the employees lived in New Jersey, he might not be able to visit the same doctors as the other employee, who lives in New York.

Patients in such plans are joining not just an HMO but also a subgroup of doctors and hospitals that they can use within it. Seeking treatment outside the subgroup is possible if the patient's subgroup agrees. But it can have disastrous consequences - something that Harry Christie, a father in Woodside, Calif., learned the hard way.

In 1993, when Christie's daughter, Carley, 9, was diagnosed with a rare kidney cancer, he wanted the best surgeon for her. The Lucile Packard Children's Hospital at Stanford University was covered by his HMO. And so was a pediatric surgeon there with experience in such cases.

But not covered for Carley, Christie was to learn three days after the operation as he sat in the hospital with his daughter. ``I get a call in the intensive care unit from the utilization nurse from the HMO saying, `Well, you didn't get pre-approval, so we're not going to pay,' '' Christie recalled.

Carley's surgeon was in the HMO, but ``he was not in the medical group we were in,'' Christie explained. The HMO argued that the family should have used a surgeon in their own medical group, a urologist who had never removed this particular type of cancer, a Wilms' tumor, Christie said.

Christie had to pay his daughter's $50,000 hospital bill, then fight the HMO, Takecare Health Plans (now part of FHP Health Care), through arbitration for a year before getting his money back. Takecare refused to pay Christie's legal costs, an amount he said rose into five figures.

Dr. Stephen Shochat, the pediatric surgeon who operated on Carley, figured he would not be paid for the surgery, but he was surprised the HMO had even refused to pay the girl's hospital bills. ``I was shocked,'' he said.

To guard against problems, consumers should:

Ask questions about the HMO's provider list. After making sure that the doctor they want is indeed with the organization, she said, consumers should check whether the doctor will be available to them.

Check out the specialist list. If they have a serious health problem or something requiring continuing treatment, it is important to make sure that specialists in the network commonly treat the illness.

Call the primary-care doctor they want to use and ask about the policy on referring patients with their condition to specialists.

Although people often pick a medical plan based on the doctors, said William Sandberg, executive director of the Sacramento-El Dorado Medical Society, figuring what doctors are really available takes work. ``It's really gotten very complicated.''

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Photo: (Color) Dr. Stephen Shochat operated on a girl with a rare kidney cancer in 1993, after which the HMO told the family it would not pay the bill because they didn't get pre-approval.

The New York Times