Starting this week, patients will have some extra help in the battle to get HMOs to pay for necessary medical treatment.
The state’s new external review law, which takes effect Thursday, gives a patient the right to an outside appeal when an HMO denies treatment a doctor deems necessary.
The state Insurance Department will submit the appeal to an independent review panel – paid by the state – and impartial medical experts will make a final ruling HMOs can’t appeal.
“This is going to be a very important right for consumers,” said Arthur Levin, director of the Center for Medical Consumers.
“This has been one of the primary issues for consumer advocates for the last six years, since managed care really arrived on the scene,” Levin said.
Here’s how the process works:
A patient first has to go through his HMO’s own appeals process, but only once.
If he loses the decision there, he has 45 days to file for an external review.
The HMO must provide a form for the state appeal when it denies coverage, but the patient has to pay the state a $50 fee for the review. The money is refunded if the patient wins.
The fee is waived for patients on Medicaid or Child Health Plus, and in cases of hardship.
The outside panel has 30 days to make a decision, except in emergencies, when it must act within three days.
HMOs must abide by the decision or face stiff penalties, said Insurance Department spokeswoman Allison Klimerman.
She said a variety of sanctions are available.
Although New York is behind 13 other states in setting up its review system, its new law is tougher than most.
It doesn’t apply to only routine denials of care, but allows patients to appeal decisions on experimental treatment and clinical trials, noted health advocate Susan Rosenfeld.
Klimerman said the external review system will operate 24 hours a day.
Information on the review process is available on the Insurance Department’s Web site, http://www.ins.state.ny.us.