- The Washington Times - Tuesday, February 18, 2003

BOSTON, Feb. 18 (UPI) — Most patient-HMO disputes involve patients seeking physicians outside of their networks and questions over which services are covered, new research revealed Tuesday.

The study, illuminating a rarely discussed process of appeals implemented by health maintenance organizations, highlights areas where healthcare guidelines require an overhaul.

"The first main finding is that most appeals cases fall into three categories," said David Studdert, study author from the Harvard School of Public Health, Boston. When patients appeal initially denied coverage, their cases involve drawing the lines to determine what is medically necessary, what is covered by the insurance contract, and whether an out-of-network physician offers something a listed provider cannot.

The latter two accounted for about two-thirds of the cases in the study, which involves data from two large California HMOs.

The findings confirm the often-heard complaints that specialists outside of HMO networks offer higher quality treatment. Almost 60 percent of appeals by patients who sought out-of-network care did so, they said, because of quality issues.

Studdert said overall about 40 percent of the time a decision was made in favor of the patient. The rate of patient wins was higher, at 50 percent, in cases that fell into the medical necessity category, reported the study, found in Wednesday's Journal of the American Medical Association.

Appeals patients lost often involved requests for elective or cosmetic surgeries, such as treatments for scars or benign lesions.

"This presses up against the public perception about what's involved in managed care cases," Studdert said, explaining the results could help policy shapers better design managed care systems. He added sometimes it is difficult to determine whether a treatment is medically necessary and more specific guidelines would help both health organizations and patients figure out what is covered and what is not.

In their study, the authors suggest oversight authorities "hone in on the disputes with the greatest potential for harm" to patients. For example, review of cases involving medical necessity could be expedited and well scrutinized while less serious appeals for elective surgery or other procedures would follow another set of guidelines.

"HMOs could prevent at least a certain percentage of appeals by being clearer in terms of the limits of benefits and delineating what is not covered," said Gerald Kominski, associate director of the University of California-Los Angeles Center for Health Policy Research.

Kominski noted a number of cases involved in the study were disputes over relatively minor matters. At the same time, the appeals process should remain an HMO practice to catch the appeals that clearly are warranted, he added. The appeals system, however, does not cover all concerns and complaints about HMOs.

"The issue of timely access to specialists is not an area necessarily addressed, but a source of dissatisfaction for HMO patients," Kominski said.

If anything, the study confirms complaints that HMOs are complicated organizations. In a different state, the study outcome might have been different, and it leaves out people who do not understand the appeals system, said Laurence Lavin, director of the National Health Law Program, Los Angeles.

"Managed care is still a complex system consumers are not familiar with," Lavin said. "It has not become easier in the last three decades as the patients' bill of rights still sits (in Congress) awaiting action."

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