AllMed Healthcare Management Blog: 06/09/06
Friday, June 09, 2006
Ohio's Patient Protection Act
http://columbus.bizjournals.com/
The Patient Protection Act was established in 1999 to give consumers a way to challenge insurers who denied their health claims. Since the program began, 2,760 cases have been evaluated and 79 percent of those cases have been ruled in favor of consumers.
Those insured by preferred provider organizations, health maintenance organizations, public employee health benefit plans or traditional insurance are eligible to have their cases reviewed.
An independent review organization working for the Patient Protection Act is required to complete reviews in 30 days, or, for cases involving serious health issues, in seven days. Any decision the review board comes to is binding upon the insurer.
posted by Dr. Skip
How Patients Covered Under A Managed Care Plan In Pennsylvania Can Appeal Medical Decisions
This appeals process isn't open to all of Pennsylvania's 12.4 million citizens. Only people insured by an HMO — health maintenance organization — or other plans in which a member has to go to a primary care physician or some other type of “gatekeeper” for a referral in order to see a specialist.
People insured by “straight,” or traditional, preferred provider organizations do not have the right to the state-mandated appeals process, according to Stacy Mitchell, director of the Pennsylvania Bureau of Managed Care, although the patient could file suit to challenge a rejection.
For people eligible to appeal an insurer's decision, the process works like this:
* An initial appeal — all appeals should be submitted to the insurer in writing — must be reviewed by the plan within 30 days.
* If that appeal is rejected, the patient can request a hearing of the appeal by a plan review committee. The plan has 45 days to hold the hearing, and then must issue a decision within five days.
* If that appeal is unsuccessful, the patient can appeal to the state's Bureau of Managed Care within 15 days. The bureau will send that appeal on to one of the nine independent review organizations — all companies like Imedecs — that are registered with the state, Mitchell said. The independent reviewer has 60 days to issue a decision.
An independent reviewer's decision is binding, within limits. Either party — the health insurer or patient — can sue if things don't go their way, Mitchell said.
There are exceptions to the time limitations at each step in instances where time is critical.
posted by Dr. Skip
