HMOs Required to Explain Denial of Care <br>By
Jordan Rau <br>ALBANY BUREAU CHIEF <br><br>October 17,
2001 <br><br>Albany - Attorney General Eliot Spitzer
yesterday announced a legal <br>agreement requiring seven
of the state's largest HMOs to provide <br>patients
with much more detailed explanations when their
requests for medical care are denied. <br><br>Spitzer said
the agreement was the result of a two-year
investigation <br>that found many HMO claim denials were so
vague or perfunctory that patients could not fashion an
effective appeal. <br><br>"It was very clear we were not
getting adequate information," Spitzer <br>said. <br>The
companies that signed the agreement are: Aetna/U.S. Health
Care, <br>Prudential Health Plan, Group Health
Incorporated, HIP Health Plans, <br>Vytra Health Plans, Oxford
Health Plans and Excellus Health Plans.
<br><br>Together, they serve about 7.5 million New Yorkers. The
companies also <br>agreed to pay $1 million total to cover
the costs of Spitzer's <br>investigation.
<br><br>While Spitzer called the agreement a landmark, the New
York Health Plan Association, an industry group,
downplayed its significance, saying that the attorney
general's investigation raised "technical issues only"
rather than unearthing evidence that patients were
inappropriately denied medical care. <br><br>"In essence, this
reaffirms existing practice, as plans are currently
<br>providing this information to members, as required by New
York's <br>External Appeal Law," Paul Macielak, the
president and chief executive of the association, said in a
statement. "The Attorney General's review of plan documents
involved cases that were at least two years old, predating
this successful law." <br><br>Since 1997, patients
have been allowed to appeal whenever their
<br>insurance company rules that a treatment is experimental or
not medically necessary. <br><br>The first stage of
the appeal is within the company, but under state
<br>law, patients who lose their appeals can then bring
their cases to health care practitioners with no
connection to the insurance company. <br><br>Spitzer said,
however, that appeals have been hampered by excessively
<br>curt HMO explanations. In one case cited by Spitzer's
office, a patient was denied further inpatient care at an
acute rehabilitation facility. The only reason provided
was that the patient could move 200 feet and up and
down 24 steps, both with supervision. <br><br>"The
cognitive functioning training will be long term, and can
be <br>continued as outpatient," the HMO ruled,
according to Spitzer's office. <br><br>Richard Kirsch,
director of Citizen Action of New York, a consumer
<br>group, said: "Many consumers, confused and frustrated by
HMO denial notices in the past, will now be empowered
to appeal. These agreements provide consumers and
their health care provider with a powerful tool."