Intended for healthcare professionals

News Roundup [abridged Versions Appear In The Paper Journal]

US strengthens rights of insured patients

BMJ 2000; 321 doi: (Published 02 December 2000) Cite this as: BMJ 2000;321:1368
  1. Fred Charatan
  1. Florida

    The Clinton administration has issued new rules giving Americans in private, employer based health plans the right to obtain faster decisions on their healthcare claims and appeals.

    The new rules will take effect in January 2002. They follow the failure of Congress to pass a bill of rights that would have given patients the right to sue companies operating managed care plans.

    Under the new rules, if a patient needs an insurer's approval before receiving medical care, the insurer has 15 days to rule on the claim. If a patient has received care and files a claim for reimbursement, the insurer must rule within 30 days.

    The current 60 days for patients to file an appeal has been extended to 180 days. In deciding on an appeal, an insurer must “consult with a health care professional who has had appropriate training and experience.”

    Until now, insurers have had 60 days or more to rule on appeals. In the future, they must meet a deadline of 72 hours for “urgent care,” 30 days for claims seeking advance approval of care, and 60 days for claims seeking payment after care is provided.

    “More than 130 million people in employer based health plans will be able to count on a faster, fairer, and more informed process for handling their claims and appeals to pay benefits,” said the labour secretary, Alexis Herman.

    Under the new rules, health maintenance organisations and insurers must give “the specific reason or reasons” whenever they reject claims or reduce or terminate benefits. If an insurer refuses to provide or pay for treatment on the grounds that it is experimental or not medically necessary, the patient will be entitled to “an explanation of the scientific or clinical judgment” that supposedly justifies the decision.

    Karen Ignagni, president of the American Association of Health Plans, which represents health maintenance organisations, said she was worried that the new rules could put patients on “a fast track to court,” creating a “litigation bonanza” for plaintiffs' lawyers.

    Charles Kahn 3rd, president of the Health Insurance Association of America, said that the new rules would probably increase the cost of health insurance, causing some employers to drop coverage for their employees.

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