Florida's HMO appeals board is rarely used
By WES ALLISON
© St. Petersburg Times, published March 23, 2001
President Bush says that HMO appeal boards could solve the frustrations of doctors and patients without costly lawsuits against managed care companies. But Florida's experience with a similar board shows the idea might not be the easy cure many are seeking.
More than 15 years after Florida created a board to review HMO treatment decisions, it is rarely used, few patients and even doctors seem to know about it, and no matter how woeful a case may seem, patients still are at the mercy of their HMO.
As with everything else, you get what you pay for: Less expensive health plans generally provide fewer services, and the review board can't change that. It must consider not just what the patient needs but whether the HMO is truly obligated by contract to pay.
The board often hears heart-wrenching appeals from dying patients or their families, who want coverage for that last-ditch treatment, their last hope. And often, the panel must say no.
"These are desperate people who are looking for anything that can help them," said Connie Ruggles, the panel's vice chairwoman. "And we're not able to tell them the plan has to do that, because it doesn't. It's not in their contract. And it's hard. Very hard."
At a cardiologists conference Wednesday in Orlando, Bush said he wants to sign a patients' bill of rights this year that would establish independent medical review boards where patients could appeal decisions by their HMOs.
Those boards would be staffed by physicians and would act quickly, and their decisions would be binding, the president said.
The idea was cheered by the audience of doctors and other health care workers, who frequently complain HMOs are too stingy with the treatment they allow.
"People who make the decisions now are not current practitioners," griped Dr. Michael Jaff, a cardiologist in Morristown, N.J., who was buoyed by what he heard from the president. "They don't review cases quickly, and patients suffer."
Bush offered little detail about how he thinks it should work. But in Florida, few patients actually find their way to the review board, which is called the Statewide Provider and Subscriber Assistance Program. Although private HMOs insure some 3.7-million people here, the panel heard just 230 cases in the first six months of the 2000-01 fiscal year, according to the state Agency for Health Care Administration.
The year before, it heard 220.
The board consists of six or seven members -- representatives from AHCA and the state Department of Insurance, a doctor and a consumer member appointed by the governor.
It meets monthly to hear disputes over what an HMO should cover. It doesn't hear complaints about fees, Medicare or issues in litigation. Its decisions are binding.
"The crux of our work has to do with actual services," said Ruggles, the vice chairwoman. "Is the plan going to pay for someone to go out of network? Is the plan going to pay for someone to go out of state? Is the plan going to send them to a specialist?"
About half the time, the board says yes. The Florida Medical Association and the managed care industry, typically at odds, agree the panel is fair.
Florida created the panel in 1985, making it one of the first of 40 states that now have them. It employs eight full-time staffers who help research and organize medical records and has a budget of $1.07-million, which comes from fees paid by HMOs.
Establishing independent review boards was just one of the elements Bush said he wants in a patients' bill of rights, but it was among the most significant, doctors said.
On Wednesday, Bush pitched such panels as a way to hold HMOs accountable without legal action. Although he said he favors allowing patients to sue HMOs over the decisions they make, the president said he would demand strict limits on damages. The leading bipartisan version now bouncing around Congress would cap damages at $5-million, but Bush said that's too high and he would veto it.
"With a strong, independent review process, most disagreements should not wind up in court," Bush said.
But to make that process strong, the president and Congress must do a better job of helping patients find the panels than Florida has done, patient advocates and physicians said.
Currently, people may petition the panel only after they have exhausted their HMO's internal appeals. Those appeals are supposed to take no more than 60 days under state law, but the Florida Medical Association and private doctors contend it sometimes takes many months.
This spring, FMA is asking the Legislature to change the law to let patients go directly to the Provider and Subscriber Assistance panel, bypassing the HMOs' internal reviews. The industry opposes that change.
"When you need medical treatment, sometimes the need passes by the time you make your way through the internal review system," said Francesca Plendl, director of governmental affairs for the FMA. "You give up."
Some critics also complain that HMOs don't tell people about the panel as the law requires, although Ruggles said AHCA has no evidence of that. Rather, many people don't realize their HMO has an appeals system.
"If they never enter the grievance process with their HMO, then they'll never get to us," she said.
Becky Cherney, a member of the Florida Board of Medicine, said her mother's HMO never told her specifically about the panel when the HMO refused to cover some of her mom's medication. Instead, she recalled hearing something about a state grievance panel, then pored through years-old grievance procedures the HMO had sent when her mom enrolled.
She eventually appealed the case, and the panel ordered the HMO to pay for the medicine. The decision came in just 24 hours.
"It was very stressful, looking through those papers. It was buried," said Cherney, who also is president of Central Florida Healthcare Coalition in Orlando, a non-profit group that measures quality among hospitals and insurers.
She acknowledged that people must make the effort to determine just what their health plan allows, but said HMOs could make it easier.
"You had to really read through it. It certainly felt like no one wanted me to find that number."
Florida's Statewide Provider and Subscriber Assistance Program:
Consists of a six- or seven-member panel that meets monthly to review appeals from patients denied treatment.
Is made up of managed care experts from the state Agency for Health Care Administration, the state Department of Insurance, a doctor and a consumer member, who is appointed by the governor. Medical specialists consult as needed.
Can be used only after patients have exhausted their HMO's internal appeals.
Decisions usually take from two days to two weeks.
Questions about appealing a decision? Call your HMO or AHCA toll-free at 1-800-226-1062. (Medicare has an independent review system. The toll-free number is 1-800-633-4227).
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From the Times state desk
From the state wire