Medicare Process Criticized Proposed Legislation May Speed Up Reviews Of Disputed Claims

Lawmakers seeking to speed up the process of challenging Medicare denials of payment for care charged Monday that the Clinton administration has failed to guarantee a swift and fair appeal system.

“Since the administration of its own volition did not go forward, perhaps it’s better that we get it right,” said Rep. Bill Thomas, R-Calif., chairman of the House Ways and Means Committee’s health subcommittee.

Along with the panel’s top Democrat, Rep. Pete Stark of California, Thomas has introduced legislation to require Medicare to hire independent experts to review claims disputes. Under the proposal, initial rulings could take a maximum of 60 days and any subsequent appeals no more than 90 days.

In February 1998, President Clinton said he would impose a “patient’s bill of rights” - including quick and impartial appeals of coverage denials - on all federal health insurance programs, including Medicare, which covers 39 million Americans.

Clinton has required the private health plans, known as HMOs, that serve about 6 million Medicare beneficiaries to provide independent arbitration of coverage disputes within two weeks. The administration is pushing Congress to pass legislation this year that would require private plans to provide all patients with similar protections.

However, the vast majority of Medicare beneficiaries, whose medical bills are paid directly by the government, have continued to face long waits for rulings when they try to challenge denials of their insurance claims.

The average wait for an initial ruling on a disputed claim for inpatient hospital service was about 52 days in 1998. Subsequent appeals to an administrative law judge took an average of 310 days. For disputes over outpatient services, the process took even longer, averaging 116 days for initial decisions and 524 days for appeals.

In addition, the initial rulings in Medicare claims disputes are made by private insurers that Medicare pays to process its bills - a potential conflict of interest, Thomas said.

At a news conference Thomas held on Monday, Baltimore speech pathologist Pat Ourand said her patients often spend years trying to get Medicare to pay for cutting-edge devices such as voice synthesizers that could help them cope with debilitating diseases such as Lou Gehrig’s.

“This is a system that is confusing, convoluted and terribly slow,” Ourand said.

Medicare officials said some delays are caused by back-ups in an overburdened system. In his fiscal 2000 budget, Clinton has asked for $10 million for improvements.

Thomas said he estimates that fixing the problems could cost as much as $1 billion to $2 billion over five years.

Michael Hash, deputy administrator of the Health Care Financing Administration, said Monday that Medicare was committed to ensuring a “timely, open process” for beneficiaries to get the services and supplies they need.

Medicare has increased its efforts to make sure beneficiaries know their rights to appeal denials of coverage and has worked with the Social Security Administration to improve the timeliness and consistency of rulings on appeals.