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New Rules Regarding Hmo Appeals On Way Changes Supposed To Strengthen Rights Of Beneficiaries

The federal government is writing regulations designed to strengthen the appeals rights of Medicare beneficiaries who disagree with coverage decisions by their health maintenance organizations.

The Department of Health and Human Services’ Office of Managed Care expects to announce the new rules by the end of the year for the 4.5 million people enrolled in Medicare HMOs.

“We are in the process of developing new policy that we think will fill some vacuum that exists … that will bring appeals and grievances policy into line with the growth of managed care,” Bruce M. Fried, director of the Office of Managed Care, said Tuesday.

Among the changes will be a system to expedite appeals for “urgently needed care” and to shorten the length of time for appeals of general care. The new policy also will require HMOs to give more information to the federal government about how many and what kind of grievances it receives.

Currently, HHS policy gives a health plan 60 days to review an initial grievance.

If the HMO rejects the appeal, the patient can take the case to the Health Care Financing Administration, the HHS agency that runs Medicare. HCFA has 60 days to consider the grievance.

“We think 60 days and 60 days is too long,” Fried said.

For example, a physician may decide it is time to change the course of treatment for a person suffering from a stroke, Fried said. The doctor could decide it’s time for the patient to go home or move to a lesser care treatment center.

If the patient or the patient’s family objects, they could wait up to 60 days for the HMO’s decision and another 60 days for the government to rule on the appeal.

“All the while, if the family wants to keep the higher level of care, they pay for it on their own,” Fried said, explaining that in those situations the HMO only pays for what the doctor recommends.

Under the proposed rules, Fried said, an urgent care appeal would be processed in a few days. And a general care appeal would take less than a month.

HCFA processed 569 appeals in October, said Ann Breslin, who works with the federal Center for Health Dispute Resolution, which handles such grievances. That’s up from 352 appeals in February, though the reason for the increase was unclear.

The proposed changes in appeals policy for Medicare HMO patients come less than a month after an Arizona federal judge ruled that the current rules governing appeals were too weak.

U.S. District Judge Alfredo C. Marquez, in an Oct. 17 opinion, ruled that the current policy are not specific enough and does not guarantee quick decisions in cases that require urgent action.

Tags: regulation