Providers back bill on denials by HMOs Legislation sets up appeals process to deal with complaints

January 29, 1998|By Michael Dresser | Michael Dresser,SUN STAFF

Complaining that managed care has turned into "mangled care," a parade of health care providers went to Annapolis yesterday to urge legislators to create a better way for patients to appeal when their health maintenance organizations deny coverage.

Physicians, social workers, hospital officials and others marshaled outrage stories and statistics in support of a bill that would set up a streamlined appeals and grievance process to deal with complaints about HMOs.

Witnesses told three House of Delegates committees that denials of claims by HMOs have grown alarmingly within the past year while successful appeals to the companies have plummeted.

"We've gone from managed care to managed cost to mangled care," said Rob Hendrickson, representing the Maryland Nurses Association.

The testimony came on a bill that House Speaker Casper R. Taylor Jr. has made a top priority in the 90-day General Assembly session that ends in April.

Despite widespread support, a similar bill died in the Senate on the last night of last year's session when time ran out. That bill passed both chambers in different versions with the support of the HMO industry.

This year, the HMOs are on board again -- hoping that passage of the appeals bill will stall the momentum for legislation they see as even more onerous.

The bill comes at a time when the public clamor to do something about managed care is even louder.

The cause of regulating HMOs rated a mention in President Clinton's State of the Union address Tuesday -- bringing a standing ovation from Republicans and Democrats.

The House bill, sponsored by Del. John P. Donoghue, does not address the issues raised by the president -- choice of one's physician and the right to be told of all treatment options rather than just the cheapest ones. It seeks to spell out appeal rights for patients whose HMOs have refused to cover procedures recommended by their physicians.

Patients have the right to appeal HMO decisions to three state agencies, but those avenues are lightly used and poorly publicized.

The Donoghue bill would concentrate regulatory power over HMO coverage decisions in the hands of the Maryland insurance commissioner. It would also give the attorney general's office authority to help consumers prepare their initial appeals through the internal review process each HMO is required to keep in place.

The bill would set deadlines for HMOs and the insurance commissioner to act on appeals, require that customers be notified of their rights and provide for an expedited appeal process in the case of emergencies. The bill would also give the insurance commissioner new powers to regulate HMO medical directors.

Donoghue, a Washington County Democrat, brought his personal physician to explain how the bill could have helped one recent patient -- a woman in her late 40s with breast cancer.

Dr. Frederic Kass III said the woman had gone through surgery and chemotherapy and had a poor prognosis. He said her doctors believed she needed more aggressive treatment and recommended a bone marrow transplant.

Kass said the transplant was approved by the HMO's primary care physician and the woman underwent weeks of tests before the HMO told her it would not cover the surgery because it was an "investigational procedure."

The patient had to postpone surgery for six weeks and hire a private attorney before the insurer finally backed down.

"This woman's time during that six weeks was literally hell," Kass said, adding that the woman now appears to be doing well.

That anecdote -- one of several heard by the committees yesterday -- was reinforced by testimony about escalating problems with HMOs. State Insurance Commissioner Steven B. Larsen, who testified in support of the bill, said he has seen more than a 50 percent increase in complaints about HMOs since last year.

D. Robert Enten, a lobbyist for the Maryland HMO industry, said the testimony was the first he'd heard about an increase in managed care denials.

Enten said the industry supports the appeals and grievance provisions of the legislation and can accept the regulation of medical directors by the insurance commissioner. He said HMOs remain opposed to another measure that would make HMO medical directors answerable to state medical licensing authorities for wrongful denials of coverage.

Pub Date: 1/29/98

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