PATIENTS’ RIGHTS: Conferees Reach Deal on Appeals Process
House and Senate conferees Thursday reached a tentative agreement on external appeals of disputes between patients and their health plans, CongressDaily/A.M. reports. Although negotiators will miss their deadline for an approved bill by spring recess, yesterday's arrangement is a major breakthrough on the issue of patients' rights. "This is a very significant provision," said Senate Majority Whip Don Nickles (R-Okla.), who chairs the conference. The tentative agreement would require all employer-sponsored plans to make available an external review process, for members claim who they have been unfairly denied care by their HMOs. Plans would be allowed to select independent external review panelists, and in turn, those panelists would select the actual reviewers. CongressDaily/A.M. reports that the "[d]isputes could be reviewed if the value of the denied benefit exceeds a 'significant threshold' that will be determined later by federal officials -- or if the denied service threatens a patient's life or health, regardless of costs." The agreement lays out three areas of review for benefit denials, including cases in which a plan says care is not medically necessary, cases in which the plan says treatment is experimental, and cases in which the insurer says a benefit is not covered by the contract because of "a dispute over the medical facts of the case" (Rovner, 4/14).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.