Appealing HMOs

March 23, 1997


Staff Writer

ANNAPOLIS - When Ron Keller's wife needed a certain type of gynecological exam last year, he assumed his health maintenance organization would pay the $70 physician's bill.

But the HMO refused to pay - something Keller at first chalked up to a relatively simple communication error. It took a year and repeated denials from HMO officials before the Big Pool electrician was reimbursed.

It's a process he doesn't wish on anyone.

"It just seems to me there is this intimidating factor that should be extinguished,'' said Keller, 49. "It shouldn't be there."


It's situations like Keller's, and ones that are worse, that are the target of legislation being sponsored in the Maryland General Assembly by Del. John P. Donoghue, D-Washington. The bill would establish a grievance and appeals process that would allow patients to seek relief from an independent panel of health experts.

"I think it's a more professional approach," said Donoghue, who chairs the House of Delegates health care subcommittee.

Under the legislation (H.B. 823), a patient who is denied coverage and then turned down by the HMO's internal appeals process, would then be able to file a complaint with the state insurance commissioner. The commissioner would be required to convene a panel to examine the case.

One of the most critical parts of the bill is that it places the burden of proof on the HMO to show that the denial of coverage was medically justified.

The bill was approved by the House of Delegates Friday.

One of the reasons the bill has moved along rather smoothly is because it is not being opposed by the Maryland Association of Health Maintenance Organizations. The organization's chief lobbyist, D. Robert Enten, said there is "clearly a perception that consumers need to have more access to their health care decisions."

He said HMOs have always supported fair procedures for resolving disputes.

"The bill would enhance that progress and that's why we're for it," Enten said.

Though there is a similar, but not identical, bill under consideration in the Senate, the differences are not significant enough for the HMOs to oppose the legislation, he said.

Donoghue said he was pleased that the bill has progressed so well - a path he said was made easier by the public outcry over well-publicized cases where coverage has been denied.

"I'm very pleased and I think it's because (the HMOs) were forced to come to the table," he said.

The appeals legislation is just part of Donoghue's health care package, which includes six different bills. One of the better-known bills would require HMOs and insurance companies to provide in-patient hospitalization benefits following mastectomies for as long as a doctor deems necessary.

The idea is to prevent the so-called "drive-by mastectomies" - cases where patients are released the same day as surgery - by putting the hospitalization decision in the hands of the health care professionals, Donoghue said.

"I fully believe that's where the decision belongs," he said.

Donoghue has other bills that address issues like prohibiting insurers and HMOs from retroactively denying payment to physicians for authorized medical procedures and allowing self-employed individuals to participate in the state's small group health insurance market.

Donoghue said he is confident about getting the entire package through the legislature

"I didn't think we'd be where we are today, that's for sure," he said.

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