HMO angst aired at Annapolis hearing

January 29, 1998|By GUY FLETCHER

HMO angst aired at Annapolis hearing

ANNAPOLIS - Dr. Frederic Kass knows all too well how patients can suffer when their managed-care provider denies coverage for potentially life-saving procedures.

The Hagerstown oncologist recalled Wednesday the story of a breast cancer patient who needed a special type of bone marrow transplant last year, only to be turned down by her health maintenance organization four days before the procedure was scheduled.

Only after waging an aggressive campaign against her HMO, including hiring a lawyer, did the woman get approval for the procedure - more than a month after it originally had been scheduled.


"This woman's time during that six weeks was literally hell," Kass told three General Assembly committees.

He was testifying in favor of legislation sponsored by Del. John P. Donoghue, D-Washington, that would require health care insurers and HMOs to establish state-sanctioned grievance processes for members who are denied coverage.

"I think it would at least provide a clear path on how to go about these things," Kass said, adding that his patient is now doing fine.

State officials now can ask an HMO to change a decision if it denies coverage but they cannot overturn the decision.

Donoghue's bill would authorize the state insurance commissioner to investigate complaints if a carrier refuses to pay for treatment and to overrule an insurer's decision.

The bill also would require the state attorney general's office to help patients prepare their appeals to the commissioner.

"If we had this in place right now, we could have avoided a whole lot of heartache," said Donoghue, referring to the ordeal of Kass' cancer patient.

Explaining that the problem is not anecdotal, Donoghue showed the committees a 2-inch-thick file filled with complaints about patients who were denied coverage.

Donoghue originally tried to get the bill passed last year, but it failed when it got caught behind a legislative logjam on the final night of the 1997 session. He gives the legislation a better chance this year, especially since it is part of the House of Delegates' Democratic leadership package.

"That helps a little bit," said Donoghue, smiling.

It also helps that the HMOs are not working aggressively to kill the legislation outright although they are asking for some amendments.

Fran Tracy, a lobbyist for Blue Cross and Blue Shield of Maryland, said her organization is supporting the bill.

"We are strongly in support of a grievance and appeals mechanism," she said.

Tracy acknowledged that if Donoghue's bill is not passed, it could open the door for tougher legislation against HMOs, such as fines and other sanctions.

"It seems to me this is the way to do it," she said of the proposed legislation.

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