INTERNAL APPEALS: 50% Of NY Consumers Beat HMOs

      New York HMOs' internal appeals processes "overturned half" of complaints "in favor of the enrollee," according to the state Insurance Department. The American Medical News reports that of the 15,000 complaints registered with the HMOs in 1997, about 7,500 were cases in which the consumer was victorious. While a new state law, scheduled to take effect in July, mandates that HMOs create an external appeals process for denied coverage complaints, AMNEWS reports the department numbers show "consumers are already getting results by taking their complaints directly to the plans." In addition, the numbers reported by the department jive with other figures reported by states that already have external appeals in place. For example, a November Kaiser Family Foundation study found that external appeals panels in 12 states ruled between 33% and 60% of cases in favor of members. Leslie Moran, spokesperson for the HMO Conference of New York, said the 50% win rate for consumers shows that "plans were addressing these concerns well before the external appeals law was passed." But consumer groups say there's another way to look at the numbers. While the "HMOs may well be doing a good job of policing themselves, the high rate of decisions overturned in favor of the patient also could mean HMOs were too zealous in initial denials of coverage," according to Arthur Levin of the Center for Medical Consumers in New York City. While both Levin and Moran agreed that many consumers may not be aware of their options for appeal, AMNEWS reports that HMO members are still more likely to "use HMO internal appeals than to complain to the state insurance department." The department, which handles cases involving late pay and denial of out-of-network services but not medical necessity, says it receives a fraction of the number of cases that HMOs receive, 37% of which it settles in the consumer's favor. However, the department did report that in 1997, its "volume of upheld complaints more than doubled," mainly due to "outcry from doctors about late payments" from Oxford Health Plans (Page, 1/11 issue).