New York Attorney General Elliot Spitzer is picking up where his pugnacious predecessor Dennis Vacco left off last year: He has subpoenaed five HMOs operating in the state for information about their urgent-care policies.
At issue is whether the HMOs require their enrollees to seek the insurers' approval before seeking emergency room care, an allegation that would violate a state law on the books since April 1997. Under the law, HMOs cannot require enrollees with symptoms that a "prudent layperson" would consider to be an emergency to first get authorization from a gatekeeper physician or an HMO call center before seeking medical help.
The five plans in Spitzer's spotlight are Blue Cross and Blue Shield of Utica-Watertown; Cigna HealthCare of New York; Kaiser Permanente's Northeast Health Plan; North AmeriCare, Amherst, N.Y.; and Oxford Health Plans of New York.
In March, Health Insurance Plan of Greater New York, under pressure from Spitzer, rescinded its ER pre-authorization policy (March 22, p. 17).
"The big bone of contention is prior authorization," said Marc Violette, spokesman for the attorney general.
Violette said the companies are cooperating with the subpoenas, issued last month, which request information about the plans' policies, procedures and enrollee handbooks.
The investigation has two prongs.
First, the attorney general's office is reviewing documents about the companies' emergency-care policies to determine compliance, Violette said. Second, the attorney general will look at whether any patients were actually harmed by pre-authorization requirements.
The attorney general could take legal action based on his findings; however, remedies by the HMOs, if necessary, would probably be voluntary, Violette said.
"Our clear belief is that these HMOs want to bring their policies and practices into compliance," he said.
Cigna said in a written statement that it had responded to its subpoena and believes the company's plan complies with the "prudent layperson definition of emergency services."
Officials at Oxford could not be reached for comment, but the Norwalk, Conn.-based insurer said in a quarterly filing with the Securities and Exchange Commission last week that it had responded to Spitzer's request on April 20 and also believes it is complying with state law.
A Kaiser spokesman acknowledged that some of documents sent to physicians had been in error but added that the company had already corrected them.
North AmeriCare said the state health department had initially approved the plan's enrollee handbook describing emergency room policies, but subsequently asked for revisions that were already in force when the attorney general's subpoena arrived, a company spokeswoman said.
Blue Cross and Blue Shield of Utica-Watertown said in a written statement that it has revised its enrollee handbook and that it is cooperating with the attorney general.
The Greater New York Hospital Association praised the attorney general's move. Member hospitals are being hurt by delayed payments from HMOs, and emergency service payment disputes are one contributing factor, the association said.
The average length of time for HMOs to pay hospitals for services rendered was 72 days as of March 31, up from 67 days at year-end 1998.
Private insurers, the GNYHA said, are particularly tardy, with delays ranging from 90 to 120 days.
"The complaints are coming in droves," said Kenneth Raske, GNYHA president. "We're pleased the attorney general is stepping up to the plate. Aggressive enforcement is the key to the solution."