Third Party Review of HMO Denials
May 13, 2001
The United States Supreme Court has agreed to hear arguments in two cases that may determine whether patients can continue to enjoy third party review of HMO coverage denials. At present 37 states have laws that allow patients to challenge their HMO's denial of medical coverage. However, several HMOs claim that the laws are invalid as a Federal law, the Employee Retirement Income Security Act (ERISA), preempts them. If the court determines that ERISA in fact preempts the state laws, HMO patients will no longer be able to question the advisability of an HMO's refusal to cover a certain procedure. Many HMO patients claim that their health has been adversely affected by such denials and that losing the ability to request an independent review could be devastating.
"Clearly these laws could be wiped out...if the court so chooses," said Jamie Court, executive director of the Foundation for Taxpayer and Consumer Rights, "so this is a real danger to state law." Research shows that about one half of all reviewed cases favor the patient. "Not to be over-dramatic, but I think it's hard to overstate the importance of these cases," said Maryland Insurance Commissioner Steven Larsen. "I personally believe [external review] is the most important part of our patient protection arsenal," he added.
-- Article Courtesy of InjuryBoard.com
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