ARIZONA: HMO Appeals Law Takes Effect Tomorrow
Arizona's new law allowing HMO enrollees to appeal treatment decisions made by their health plans takes effect tomorrow. The Capitol Media Services/Arizona Daily Star reports that the law "has a three-step appellate process for patients," with the first two steps "tak[ing] place within the HMO" (Fischer, 6/30). First, a patient can request an informal review of a denied claim, and the HMO "has 30 days to respond." A formal appeal can be requested within an additional 60 days if a patient remains unsatisfied with the informal review. The "final step" is to file "a written request for an independent, external review" ( Capitol Media Services, 6/30). When it comes to external reviews, the HMO is allowed "to choose one or more independent medical reviewers who have no financial interest or connection to the case."
State Sen. Ann Day (R), who introduced the new law last August, "said the new plan can work -- if the Department of Insurance does its job." She expressed concern that the independent medical reviewers "chosen and paid by the HMOs" would make the process "really independent." She said it is possible that "the reviewers might side with the insurer to guarantee future jobs." However, she noted that the Department of Insurance is empowered under the law to remove problematic reviewers from the HMOs' list.
A spokesperson for the insurance department noted that up to 40% of Arizona employers could be exempted from the state law because their health plans are self-insured, thus falling under federal regulation (Fischer, 6/30). Click here to see the text of the new Arizona HMO law.