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Appeal bill too complex

March 30, 1999

Many Pennsylvania residents who get their medical care through health-maintenance organizations have had the right to appeal certain HMO decisions since January. But state officials say there's only been one appeal statewide, prompting them to begin a new information campaign about the law. A good idea, we'd say, given some of its more complicated provisions.

The law is called Act 68, or the Quality Health Care Accountability Act. It specifies, among other things, that women in managed-care plans can see their gynecologists for routine or maternity care with first getting permission from their primary-care doctors.

The new act also requires managed-care plans to pay for emergency care when a reasonable person, as opposed to an HMO, would conclude that emergency treatment is necessary. Perhaps most important, patients who are denied care they or their doctors feel is necessary can have that denial reviewed by a state-appointed board.

It all sounds good, but the law also contains some complicated provisions that would probably challenge the patience of a healthy person, let alone someone who's sick.

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The first is that Act 68's rights don't kick in until the patient renews his or her coverage in 1999. If you don't renew your policy until September, any decision the HMO makes until then can't be appealed.

Assuming that you are eligible for appeals, the bill doesn't make that process simple either. First the patient must decide whether to make a complaint or a grievance. Complaints deal with services the patient wants that aren't covered, and how well the plan is managed. Grievances deal with services already rendered that the plan won't pay for, or for those services a doctor feels are medically necessary which the plan refuses to pay for.

In either case, before going to the state board, the patient must go through a two-step appeals process with the plan. There's a 48-hour deadline when the patient's life is in jeopardy, but the upshot is that this whole procedure is still too complicated for someone who's ailing. State lawmakers should simplify it as soon as possible.

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