With prospects for a patient bill of rights far from certain, tens of millions of Americans will enjoy a speedier appeals process next year as a result of regulations the Clinton administration passed in its waning months.
"We think (the regulations are) a positive step to improve patient protection," says John DuMoulin, director of managed care and regulatory affairs at the American College of Physicians-American Society of Internal Medicine in Washington. "Doctors are advocates of their patients . . . so it's helping physicians provide the service that patients need."
The regulations on healthcare claims and appeals, set to take effect in January 2002, were a last ditch effort by the administration to increase patient protection. For at least two years, the White House and Democrats on Capitol Hill, along with a sizable minority of Republicans, have been trying to pass a patient bill of rights, only to see their efforts blocked by Republican leadership in both houses.
Just prior to the issuance of the regulations, some House Republicans urged the administration to allow lawmakers to come to a compromise and hold off on issuing regulations until that happened.
The new regulations are the first change governing the claims and appeals process in 20 years. The changes call for:
- Faster decisions on initial claims. Rather than 90 days or more under current regulation, the new rule requires decisions in most cases not later than: 72 hours for urgent care claims; 15 days for pre-service claims; 30 days for post-service claims. It includes one 15-day extension for pre-service and post-service claims.
- Faster decisions on appeal of denied claims. Rather than 60 days or more under current regulation, the rule requires decisions in most cases not later than: 72 hours for urgent care claims; 30 days for pre-service claims; and 60 days for post-service claims.
- Speedier appeals process. Claimants will have more time to file appeals: 180 days, rather than the current 60 days. If treating physician determines the claim is "urgent," plans must treat it as urgent.
The plans cannot impose fees or costs as a condition to filing or appealing a claim. Arbitration is permitted but only with full disclosure regarding the process, arbitrator, relationships, right to representation and only if the claimant agrees after completing internal appeal.
The review must be de novo, and the decisionmaker on appealed claims must be different than the person deciding the initial claim.
Plans may not require more than two levels of review of denied claims. If more than one level exists, both levels must be completed within time frame applicable to one level.
If the plans fail to make timely decisions or otherwise fail to comply with the regulation, claimants will be able to go to court to enforce their rights.
- Fuller disclosure. Plans must provide participants with a full description of the plan's claim procedures. Plans must provide specific reasons for denials, including identification of and access to any guidelines, rules and protocols relied upon in making the adverse determination.
"Patients will be positively impacted because they will go to emergency care with more confidence that they won't be denied payment," says Steve Pilon, M.D., an emergency physician in Albuquerque, N.M. "It will shift decisionmaking power somewhat toward the prudent layperson" standard required in many states. The regulations, he says, will also improve physicians' chances for reimbursement.
But Steven Wojcik, director of public policy at the Washington Business Group on Health, argues that the regulations "seem to give a fast track to bypass existing procedures and to go to litigation. That would be a cost factor that employers would be concerned about."
Susan Pisano, spokesperson for the American Association of Health Plans, says that even slight or immaterial deviations from the regulations by a health plan will allow enrollees to claim, "I've exhausted this (the appeals process), I'm going to court."
Pisano also cites possible conflicts between state and federal regulations.
"(The appeals process) is heavily regulated by all states and there's not a lot of guidance as to what applies" in particular circumstances, Pisano says.
Even with the regulations, patients still don't have enough protection, Pilon says.
"This is a stopgap measure," Pilon says. "We do need a patient bill of rights." Indeed, doctors' groups will continue pushing for legislation and members of Congress who sponsored such bills are likely to reintroduce them again despite dim prospects for passage.