MEDICARE HMOs: Reax To This Week’s Big Court Ruling
The Health Care Financing Administration may appeal a new 9th U.S. Circuit Court of Appeals ruling "that requires beefed-up appeals rights for Medicare beneficiaries enrolled in HMOs," the Wall Street Journal reports. HCFA spokesperson Chris Peacock said agency lawyers are "studying the opinion ... and [haven't] decided whether to appeal further" (McGinley, 8/14). The government is particularly critical of the appeals court's determination that "Medicare beneficiaries were entitled to due process because the HMO decisions amount to 'government action.'" Health and Human Services spokesperson Melissa Skolfield said, "We absolutely believe in a strong, independent appeals process, and we have taken steps to strengthen the appeal rights of Medicare beneficiaries. But we have concern about the judge's finding that private HMOs should be treated as if they were the government."
Today's New York Times notes that the "government issued rules to define Medicare appeal rights in April 1997, and Congress adopted similar requirements last August." But the Center for Medicare Advocacy's Sally Hart, the attorney who represented the plaintiffs in the class-action suit that prompted this week's ruling, said, "Many beneficiaries are still not receiving written notice when services are denied," despite the 1997 government rules. Vicki Gottlich of the Senior Citizens Law Center notes that the ruling "goes much further" than the current rules. The Times reports that the ruling specifically tightened the deadline that Medicare HMOs must meet in responding to patient requests for services. While the "federal rules say that an HMO must ordinarily rule in 14 days on a request for services from a Medicare patient," this week's ruling "allows just five days."
The HMO Industry Reax
American Association of Health Plans President Karen Ignagni on this week's ruling: "We were comfortable with the Medicare rules issued in 1997. They made important changes that responded to beneficiaries' concerns. We want to study the court's decision to compare it with those rules" (Pear, 8/14). Click here to read coverage from yesterday's American Health Line of the 9th Circuit Court's ruling.