Disappeared News

Larry, thanx for the link, but can you translate into English?

If the Conference Committee report is to be believed (?!?), the change is necessary to comply with the federal health care reform law and is based on model legislation from the National Association of Insurance Commissioners. The bill appears to substitute a third party review for the current appeal to the Insurance Commissioner. Is this a sham? Are these reviewers beholden to/aligned with insurers such that they will inevitably agree with insurance company denials?

Explanation/clarification, please, so that we know what we're talking about when we urge the Governor to veto?

Mahalo!
 

The bill does several things. First of all, Hawaii's law exceeds the federal requirement, it does not need to be repealed. At most, a new law could simply provide for a third-party independent review as an alternative (option).

By repealing the definition of medical necessity from statutes and leaving it to the insurers, they, not the statute, will determine what treatment is "necessary." That's already quite dangerous.

The review panel would be some Mainland firm selected by the insurance company. Since they would like to have their contract renewed, there is a disinclination to find against the insurance company that is built into the system. This is the same problem as with arbitration clauses in contracts.

Also, patients could no longer afford the appeals process. Currently, if the Insurance Commission hears an appeal, the patient can recover attorney's fees even if the patient doesn't prevail. This is essential, since otherwise the cost of representation would not only be higher than the cost of treatment, but it could drive the family into bankruptcy. The insurer has in-house attorneys and experts and their cost is minimal.

And finally, without the external review process, insurers can be expected to increase denials of all sorts. Why not? That is how they make their profits.
 

OK, I get the gist here but, while it may not matter in the end, you appear to be mistaken about some of the details:

1. The independent reviewers are selected by the Commissioner, not by the health insurer, and must not be affiliated with, owned, etc. by a health insurer. However, the bill is contradictory with regard to whether that selection must follow procurement laws. Also, the review must be paid for by the insurer but there is no recourse against the Commissioner if the insurer doesn't pay. So, I guess it's reasonable to infer that the reviewer will make decisions favorable to insurers if it doesn't want to have to sue to get paid for the review.

2. It doesn't appear that the definition of "medical necessity" is repealed in the bill, altho' it is amended to add the words "meets the criteria enumerated" in section 432E-1.4. In fact, the term is added to the statutes in about 10 places, according to the bill.
 

This year there was no attack on our medical necessity statute. That is coming next year and I have already seen the preview. Get ready, as SB1274 had LOTS OF INSURANCE LOBBYISTS pushing every day for it.
In the majority of the 49 states, patients had resort to independent review organizations to appeal a denial of coverage. The IRO is a doctor somewhere who gets the file and says whether you can have the benefit or not. The doctor is drawing conclusions of law and medical issues. In most of the states the doctor's decision is not reviewable and not appealable and the plans paid the IRO fees. No appeal from one individual's final and binding decision no matter what was involved in your case, life/death, whatever.
You saw "Sicko" right?
Hawaii has never had sicko. There have been some coverage denials. When the patient appealed, in most cases the appeal was to the Ins. Comm for a review. The Commr is required to appoint a panel consisting of 3 persons, a doctor, a lawyer, and a plan administrator from a competing plan. They are required to hold a hearing, with any witnesses either side wants to call, according to rules for hearings by admin agencies.
Either side has the right of appeal, but if the patient wins, there is no stay from the decision and thus the plan has to pay.
The law was designed to be a private attorney general statute. The Legislature determined that the law should be enforced, but instead of hiring a deputy AG, set things up so that patients could hire private counsel and experts and would be indemnified against those costs - the public benefits too so the patient should not have to pay and the patient should not have to pay to get coverage to which she is already entitled
Patients prevailed over 80% of the time. Complex (80-100 page) plan documents got interpreted by people with the training and skills to do that. Experts were consulted on their opinion of the treatment.
Compare the two processes and just comment about which you would rather have if you were diagnosed with something terrible that was treatable but, ala "Sicko," your plan said NO.
 

Looking at the status sheet, I see that this is the GOVERNOR's own bill! Did it morph in the process or was it bad from the start? Either way, why would he veto his own bill?
 

One correction on the appeal discussion: The decision of the 3-person panel is appealable, but immediately enforceable by the patient. The plan can appeal a decision in the patient's favor, but that does not delay enforcement of the order to provide coverage.
The majority of our legislators voted for the IRO process based on an unfounded fear. Despite heavy lobbying for the IRO by health plans (now why would they do that if it was better for you?) many of our legislators were, and still are, concerned about losing our long-standing process (some were not - draw your own conclusions - you might want to reseach who gets contributions from health insurance). They voted yes on the bill because they felt compelled to in the information vacuum the feds are partly to blame for creating (make sense to you to vote in a vacuum?). A handful, Belatti, Hanohano, Rhoads, Takai, Takumi, Thielen, and Slom thought that was a bad idea.