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View Diary: My Health Care Nightmare Story (12 comments)

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  •  What worries me is that without a public option (1+ / 0-)
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    all we have are laws that make insurance companies cover people with pre-existing conditions or people that are currently uninsured.

    As Norm has shown, even when an insurance company pays a claim, the put you through hell to get money owed.  (Just think of how much of our premiums go to the "panel" of experts denying your claim.)

    Even with the new laws, the insurance companies can screw over customers.  If they complain, it's "so sue me."  How long will it take for lawsuits to be pursued or for a state attorney general to see the problem and force the insurance company to honor the federal requirements?  (And forget any legal pursuit if your state's AG is Republican.

    The land was ours before we were the land's...Robert Frost, The Gift Outright

    by HylasBrook on Thu Aug 20, 2009 at 02:25:59 PM PDT

    •  ERISA & FEHBP appeals (0+ / 0-)

      ....If the appeal involves a decision based on medical judgment, including whether an item or service was medically necessary, the health plan must consult with a "health care professional who has appropriate training in the field of medicine involved in the medical judgment."

      The health care professional must not have been involved with the initial decision or be a subordinate of the initial decisionmaker.

      Upon request, the health plan must disclose the identity of the health care expert it consulted.

      Health plans cannot require more than two levels of internal review of denied claims, and if there are two levels, both levels must be completed within the time frames required of one level.

      The "fullness" category relates to improved access to information by persons appealing an adverse determination. As an initial matter, the plan must provide all plan members with a full description of the plan's claims and appeals procedures.

      Claimants appealing an adverse determination must have access to any information relevant to their claim upon request and free of charge.

      Relevant information includes any information the health plan relied on in making the initial decision; any information submitted, considered, or generated while making the initial decision; and any statements of policy or guidance concerning the denied treatment or benefit, even if such documents were not relied upon in making the decision.

      In addition, when a health plan denies a claim based on a protocol or guidelines, the plan must disclose such reliance and inform the claimant that a copy of the protocol is available upon request.

      Similarly, when the denial is based on medical necessity, the rule requires the plan either to explain the scientific or clinical judgment used in applying the plan's terms or to include a statement that such an explanation will be provided free of charge if requested.

      FEHBP appeals

      ....Neither the FEHBP statute nor its implementing regulations define "medical necessity" or how health plans are to make such determinations.

      The FEHBP regulations, however, do offer enrollees a right to appeal to OPM if the health plan denies a claim a second time after reviewing its first denial or if it fails to respond to an enrollee's request for reconsideration of a claim's denial.

      The enrollee must exercise the right to appeal within 90 days of the health plan's decision, or within 120 days of the request for reconsideration if the health plan failed to respond.

      In reviewing the claim denied by the health plan, OPM may (1) request that the claimant submit additional information; (2) obtain an advisory opinion from an independent physician; (3) obtain any other information it believes is required to make a decision; or (4) make its determination based solely on the information the claimant submitted with the request for OPM review.

      Neither the OPM statute nor its implementing regulations specify the standard OPM is to use in reviewing denied claims.

      If a claimant wishes to sue, the suit must be filed in Federal court to review OPM's final action on the claim, but the claimant is limited to ERISA remedies.

      The suit must be brought against OPM, not the health plan or its contractors, and a recovery in such a suit is limited to a court order directing OPM to require the health plan to pay the amount of the benefits in dispute.

      The ERISA regulations do not contain a right to an external appeal, despite providing important additional access to information and better claims procedures not previously available.

      The FEHBP, limited to Federal employees, provides a right to appeal outside the health plan to the OPM or to Federal court if necessary, but, as with ERISA plans, monetary damages are limited to payment for the cost of the denied benefit itself (i.e., punitive and "pain and suffering" damages are not available).

      As a result of the modest reach of Federal law, the definition of medical necessity is still governed by the terms of the contract negotiated between buyers and sellers.

    •  Even with a public option (1+ / 0-)
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      people getting employer coverage will still have problems since the denial incentives won't change.

      And the legislatively leading reforms steer people towards employer-based coverage.

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