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Patient's Bill of Rights to Offer Right to Appeal Denied Claims

WebMD Health News

April 14, 2000 (Washington) -- After weeks of closed-door sessions, congressional negotiators Thursday night reached a tentative deal to guarantee patients in managed care plans the right to dispute decisions to deny claims.

"This is a substantive, significant agreement that will guarantee patients have access to an independent medical review if a plan denies them health care," says Sen. Don Nickles (R-Okla.), who is chairing the House/Senate team of lawmakers that is trying to craft a compromise "patient's bill of rights."

Under the "conceptual" agreement, patients could get an independent review if a disputed claim "exceeds a significant threshold," or puts life or health at risk. The review would be done by at least one doctor with an outside firm that would be selected by the plan, and federal standards would aim to ensure that the firm would have no conflicts of interest with the managed care plan. Plans could charge patients $50 for each review, which would be refunded if a patient won the appeal.

The deal is a compromise between the appeals provisions in the House and Senate managed care bills. The House-passed measure, backed by doctor groups, had allowed for at least three physicians to review an appeal. And the Senate legislation, favored by health insurers, had permitted plans to determine what claim denials were appealable.

While the agreement signifies progress toward final managed care legislation, some of the details remain to be worked out, such as the timeline on external appeal decisions and how these decisions would be enforced.

American Association of Health Plans spokesperson Mobit Ghose tells WebMD, "We are for external review ... [but] it's going to matter how they're going to structure and create the process of who goes where and when."

American Medical Association President Thomas Reardon, MD, tells WebMD: "I think the principles are there. It's certainly a step in the right direction. It's not the end-all."

Indeed, major pieces of the overall patient's bill of rights are still unresolved, especially the highly contentious question of the legal rights that injured patients would have against plans and how many Americans would receive the bill's protections.

Dennis Fitzgibbons, spokesman for Rep. John Dingell (D-Mich.), tells WebMD, "They haven't gotten to the big issues -- who's covered and how to enforce your rights. The external appeal [agreement] begs the question of accountability."

The negotiators have agreed already to allow parents in managed care plans to designate a pediatrician as a primary physician for their children. And House and Senate lawmakers have signed off on standards to guarantee coverage of emergency room visits.

Nonetheless, negotiators have long passed their end-of-March deadline for finishing work on a final bill, but with "good faith" still a buzzword for their talks, that is not a major concern. "We will forge ahead toward our goal of sending a bill to the President as long as we continue to have constructive negotiations," Nickles says.

More progress will have to wait until next month at the earliest, as Congress has left Washington for Easter recess. The Senate will return in a week, but House lawmakers are away until May.

But even when they return, some are not convinced a final bill will pass this year. "I am concerned that they might not do anything," Reardon tells WebMD. "They have plenty of time to get a strong bill of rights passed. I think it would be extremely dangerous not to get this passed in an election year. If I were them, I'd be listening to the people."


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