- The Washington Times - Tuesday, November 21, 2000

The Clinton administration issued regulations yesterday that give 130 million private-sector employees the right to have faster decisions on their health care claims and more time to appeal when their health plans deny coverage.

The regulations, due to take effect in January 2002, are meant to significantly streamline a claims process that can leave patients waiting months for approval of a health procedure. They say health maintenance organizations, or HMOs, must notify patients of the outcomes of their claims within 30 days, with a possible 15-day extension, and render a decision on their appeals of denied claims within 60 days.

The new rules are the first changes to the claims and appeals process since the 1974 passage of the Employee Retirement Income Security Act, which covers health plans offered by employers.

Their approval by the Clinton administration came after Congress gridlocked on passage of patients' rights legislation that would have given patients the right to sue managed care plans.

"We are taking an important step toward providing Americans the health care protections they need," President Clinton said in a statement. "It is the final executive action I can take to provide critical patient protections."

But Mr. Clinton added, "the only way to give every American in every health plan the right to see a specialist, to go the nearest emergency room not the cheapest and to hold health care plans accountable when they cause harm, is to pass a real, enforceable patients' bill of rights."

Department of Labor officials said a patient could sue a health plan that does not comply with the regulations but, otherwise, the new rules do not address the liability issue that has caused much debate on Capitol Hill.

The House earlier this year passed legislation giving patients the right to sue health plans for inadequate care, but Senate Republicans have argued that it would raise health care costs and spawn a barrage of new lawsuits.

House Republicans in recent weeks urged the administration to give lawmakers a chance to pass managed care reform.

"It would be inappropriate for administrative regulations … to be issued by the department while these deliberations are under way," Republican Reps. Bill Goodling of Pennsylvania and John A. Boehner of Ohio wrote in a Nov. 5 letter to Labor Secretary Alexis M. Herman.

Mr. Goodling is the chairman of the Education and the Workforce Committee, while Mr. Boehner heads the committee's employer-employee relations subcommittee.

Yesterday, a spokesman said Mr. Boehner remains concerned the regulations will "cause employers' health care costs to increase, which will obviously cause them to drop their employer-based health care structure."

Officials at the American Association of Health Plans said the government had made significant changes since it proposed the rule in September 1998.

Still, the association's spokesman, Susan Pisano, said health plans want to ensure the new rules don't become a "trough for trial lawyers."

"That concern is still there," she said.

Under the new rules, health plans must make a decision within three days on urgent-care claims, 15 days on pre-service claims and 30 days on post-service claims. The plans would get one 15-day extension on pre- and post-service claims.

Appeals would have to be decided within 30 days on pre-service claims and 60 days on post-service claims. The urgent-care appeal also would have a three-day limit.

Additionally, the regulations give claimants 180 days to file appeals. They currently have 60 days. Health plans will have to disclose the names of any medical professionals consulted as part of the claims process, and appealed claims will be decided by a party other than the official who initially denied the claim.

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