Seeking relief from HMOs

By Mary Deibel

Patients still have some help available when fighting their HMO, even though a Supreme Court ruling stops people from using state laws to sue their managed-care provider for damages should it refuse to cover care that a doctor deems necessary.

The justices ruled unanimously in their just-concluded term that a 1974 federal statute pre-empts state patient-protection laws and allows only limited claims in federal court for reimbursement of a denied health benefit, not damages for complications that denied treatment can cause.

That leaves it to Congress and the president to step in, resuscitating patients' rights as a 2004 campaign issue. HMOs and other managed-care providers may take the high-court decision as a green light to step up denials of medical claims. If so, you'll have to make your voice heard with your elected representatives in Washington. They are already highly attuned to health-care lobby concerns.

More denials of treatment will mean more people appealing medical bills, starting with internal appeals to HMO administrators and their superiors.

What consumers need to know is that the Supreme Court didn't touch laws in 41 states and the District of Columbia that allow independent doctor panels to review instances of denied treatment, including reviews within 24 to 72 hours in critical cases.

If you're taking issue with an HMO, check out "State Health Facts" at Kaiser Family Foundation's Web site for details of the independent review process set up by your state.

For now, if you're one of the 130 million Americans covered by managed-care plans through work, health-care advocate Ron Pollack of Families USA warns that the Supreme Court ruling "takes HMOs off the hook for any liability," leaving it up to you to learn how to make your insurance work for you.

That means:

_ Study the fine print to see what services are covered and what are not.
_ Be sure to notify your insurer if required within 24 hours of visiting the emergency room.
_ Get everything approved in writing before you undergo elective procedures.

Those whose employers provide flexible spending accounts, which let you save before-tax dollars to cover unreimbursed medical costs, should consider putting money in them to cover what the HMO won't pay for.

"People who don't keep up with changes in their employer health plan can be stunned when the same prescription they got last year for $10 suddenly has a $50 co-payment," says Jeff Kelson, a tax partner with the national accounting firm BDO Seidman.

"For them, flexible spending accounts have become a sound backstop," Kelson says. "But employees need to plan carefully because the money in these accounts is use-it-or-lose it by year end."

Meanwhile, bone up on the politics of patients' rights in the run-up to the Nov. 2 elections in your local House and Senate races as well as the presidential contest.

Democrat John Kerry promises to push a federal patients'-rights bill if elected president. He points to legislation that already "has bipartisan support. It could become law if the Bush administration was not standing in the way," he says.

The bill _ co-sponsored by Kerry's running mate, Sen. John Edwards, D-N.C., and Sens. John McCain, R-Ariz., and Edward Kennedy, D-Mass. _ would regulate HMOs and other managed-care providers and allow patient lawsuits.

The measure first passed the Senate in 2001. But Senate Republican leader Bill Frist of Tennessee says there isn't time to take it up again, let alone resolve differences with the House and White House, before Congress recesses so lawmakers can campaign for re-election.

George W. Bush campaigned on the issue in 2000. At that time, he championed the Texas law that the Supreme Court killed last month _ even though the 1997 statute was enacted without then-Gov. Bush's signature.

"I do support a national patients' bill of rights," Bush said Oct. 17, 2000, in the final presidential debate of the campaign. "If I'm president, people will be able to take their HMO insurance company to court. That's what I've done in Texas, and that's the kind of leadership style I'll bring to Washington."

But the Bush administration fought to kill that same Texas law in the Supreme Court, and it is fighting in Congress for national limits on damage awards in health care, malpractice and personal-injury suits as the price of patients'-rights legislation.

The administration contends that out-of-control damage awards cost employees and employers in the long run and need to be capped. But the nonpartisan Congressional Budget Office disputes that claim, estimating that the lawsuit limits the White House seeks would save only one-half of 1 percent on insurance costs.

That's why the Supreme Court decision to cut out state efforts and toss the issue to Congress and the president likely will prolong the federal stalemate.

Patients' rights have taken a backseat to the economy and the war on terror in 2004. But with Americans rating HMOs as the nation's least trustworthy institutions, according to a new Gallup Organization Tuesday Briefing, expect the public to send a message to Washington:

That people want federal action on patients' rights, when proper medical care is as much a life-and-death matter to most Americans as Osama bin Laden.

Also on the Net: (The case name is Aetna Health Inc. v Davila)

2004 Scripps Howard News Service. All Rights Reserved.

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