Donoghue's legislation targets HMOs

March 08, 1998|By GUY FLETCHER

Donoghue's legislation targets HMOs

One day last year a 6-year-old girl, having been very sick for several days, was taken to Dr. Allen W. Ditto for treatment.

Ditto, a Hagerstown physician, noticed evidence that the girl was dehydrated, so he had her admitted to Washington County Hospital, where she was given fluids through an intravenous tube. A day later the girl was able to drink some liquids on her own, but Ditto decided she should stay in the hospital a second day.

"I wouldn't have sent my kid home. It was needed," he said.

But several weeks after the girl was safely discharged, Ditto received a letter from the girl's managed-care provider telling him that the second day of hospitalization would not be covered by the plan.


Ditto can list many other cases where patients were treated and later denied coverage.

"These aren't horror stories. This is every day stuff," Ditto said.

Many physicians and hospital officials throughout Maryland are hoping for some relief through legislation being proposed by state Del. John P. Donoghue, D-Washington. His bill would prohibit health insurers and health maintenance organizations (HMOs) from denying payment for services already preapproved by the carriers.

Donoghue, who chairs the House of Delegates' health care subcommittee, keeps a file with scores of documents detailing cases where patients had coverage denied after they were treated. Most of them are emergency cases, and include patients with gastrointestinal bleeding, back pain, or a broken leg.

Upon further review, the carriers found at least part of the treatment was medically unnecessary in those cases and would not pay the hospital or physician.

"They said, 'Whoops, we made a mistake. That really wasn't necessary,'" Donoghue said.

Bev David, director of patient access and managed care contracting at Washington County Hospital, said there are no specific figures available yet, but she said a great many of the 730 days of treatment insurers and HMOs denied last year were likely retroactive rejections.

Each day of denial costs the hospital between $800 and $1,000, David said.

"That represents a considerable amount of money related to direct services that we've provided," said David, who supports Donoghue's bill.

But Robert Enten, a lobbyist for the Maryland Association of HMOs, said he strongly opposes Donoghue's legislation, which only allows for retroactive denials in cases of fraud.

"Well, fraud is a very difficult thing to prove. There has to be an intent to deceive," he said.

Enten said there are many other cases where the HMOs are wrongly billed, often through bookkeeping and clerical errors, and they would like to maintain their ability to collect after treatment.

"With this bill, you would never be able to recover that money," he said

The bill also wouldn't let insurers and HMOs make decisions on what was and wasn't medically necessary for a particular patient after their officials already preapproved the treatment.

Ditto said the problem is a patient might come to a doctor with a seemingly serious condition, like chest pains, only to find out after a series of tests that it's just indigestion. In those cases the HMOs will use the power of hindsight to determine the tests were not needed, he said.

But the doctors have to react to the emergency as it happens, he said.

"I'm going to tell you, a lot of times in medicine you can't tell ... what is wrong with them, or you don't know right away," Ditto said.

For example, last April Ditto treated a woman who was suffering severe abdominal pain, so she was admitted to the hospital. She was given pain medication and tests, but the cause of her pain couldn't be found. Eventually the pain went away and the woman was discharged.

But Blue Cross and Blue Shield of Maryland told Ditto it would not cover the day in the hospital. In a letter to Ditto last September, the company wrote, "Observation of the patient, while appropriate, could have been carried out in an environment established for that purpose."

That one sentence so astounded Ditto that he complained in a letter to the Maryland Insurance Commissioner.

"I don't know about you, but it seems to me a very sick lady with severe abdominal pain not responding to narcotic medication certainly needs observation. I also don't know what your feeling is, but it sounds to me that an appropriate place might be a hospital," Ditto wrote.

Ditto said the issue of retroactively denying coverage probably doesn't get too much attention because it is the hospitals and doctors, not patients, that don't get paid. In fact, patients who are denied coverage will receive a letter telling them they are not responsible for the charges.

"You don't have to worry because you're not out of pocket anything," Ditto said

But he said it should concern patients that their doctors are being forced more and more into battles with carriers. Ditto's "zero-tolerance" approach to the issue has him routinely complaining in letters and phone calls.

"I spend my time on the phone with this when I should be spending my time helping folks," he said.

David argued that patients do eventually pay. If a hospital must adjust its budget to account for the hundreds of thousands of dollars lost from coverage denials, it is going to affect room rates, she said.

"In some abstract, traceable way, it gets traced back into rates, and the insurance company didn't have to pay for it," she said.

But Enten, the HMO lobbyist, argued that Donoghue's legislation would only increase costs for health care carriers and, ultimately, for consumers through higher insurance rates.

"There's like this fiction out there that whenever we have to spend money on something, it gets absorbed by the plan," he said.

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