The final rule regulating health plan claims procedures covered by the Employee Retirement Income Security Act (ERISA) was published in the Federal Register on Nov. 21st, 2000. Â It will give employees covered by private, employer-sponsored health plans the right to a faster and fairer settling of their health care claims and appeals. Â When announcing the new rule, President Clinton urged further legislative reform of managed healthcare, saying that what Americans needed was "a real, enforceable patients´ bill of rights".
Speed and Accountability
Initial claims decisions are now divided into two groups -- urgent care decisions and all other claims. Â Health care plan providers must rule "as soon as possible" on urgent care claims with a maximum 72-hour deadline to report the decision to the claimant. Â All other claims must be resolved within either a 15 or 30-day time limit, depending upon whether the patient needs approval before treatment, or is filing for a reimbursement. Â The earlier legislation allowed 90 days for all claims decisions.
The issuing of appeals decisions will also be speeded up. Â Instead of the original 60 days, plan providers now have just 72 hours to respond to urgent care appeals, 30 days for advance care appeals and 60 days for appeals involving reimbursements.
When a claim is denied, plan providers must give an explanation and supply the claimant with any supporting rules, guidelines or policies used in the decision. Â As well, if a client is denied treatment because it is considered "experimental or not medically necessary" then the plan provider must supply the scientific or clinical information upon which its decision is based.
Consistency
Plan providers are also held accountable for treating all
claimants consistently. Â According to
the rule, "a plan''s claims
procedures must include administrative safeguards and processes designed to
ensure and to verify that benefit claims determinations are made in accordance
with governing plan documents and that, where appropriate, the plan provisions
have been applied consistently with respect to similarly situated claimants". Â But how these procedures are designed and
carried out is left to the discretion of the health care plan providers.
Appeals
The regulation provides new protections for those seeking appeals -- they cannot be charged a fee for appealing a decision and they can appeal a second time if they are not satisfied with the first decision. Â The regulation provides for the right of the claimant to sue their health plan provider for wrongful denial of care but the necessary legislation is not yet in place. At present a group health plan can only be sued for non-compliance with the regulations.
Is It Enough?
Insurers and HMOs have time to prepare -- the new rules apply to claims filed after January 1st, 2002. Â According to statistics from the Labor Department, 1.4 billion health insurance claims are filed annually and approximately 14 million of them do not meet these new standards. Â The new rules apply to over 130 million Americans with employer-sponsored health plans but leave out 38 million others who have individual insurance coverage. Â As well, legislation giving patients the right to sue their plan or HMO for wrongful denial of care was passed in the House earlier this year but was then rejected by Senate Republicans. The new legislation will not override the 33 state laws that require managed care plans to have external review procedures.
There will be More
In the last two weeks, HR.com has covered three new regulations that have been controversial, but nonetheless have been rushed through the regulatory process in the last months of the Clinton administration. Â These include the Occupational Health and Safety Ergonomics Standards, the OFCCP´s new affirmative action requirements and today´s story on employees´ health care benefit claims. Â This "regulatory rush" is not over yet as regulations concerning the H-1B visa program and new rules to protect the privacy of medical records have been promised -- stay tuned.
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