SUPREME COURT DECISION UPHOLDS CONSUMERS' RIGHT TO EXTERNAL REVIEW OF HMO DECISIONS

Maryland Attorney General J. Joseph Curran, Jr. called yesterday's Supreme Court decision that supports consumers' rights to external review of HMOs' denials of health care, a win for Maryland consumers. The decision in the Rush v. Moran case, which can be viewed at http://supct.law.cornell.edu/supct/, upheld the external review mechanisms currently in place in 42 U.S. states.

Maryland is one of only 22 states that can actually provide assistance to consumers who are appealing health insurance denials. The Health Education and Advocacy Unit (HEAU) in the Attorney General's Consumer Protection Division can assist consumers who are trying to get their insurance carriers to provide coverage. If those efforts fail, HEAU can help the consumer file a complaint with the Maryland Insurance Administration (MIA). In cases where the care requested involves a determination of medical necessity, MIA can have an independent physician review the care denied. If the care is found to be medically necessary, then MIA can order the insurance carrier to provide coverage for the care.

"The decision will ensure that a larger number of people are not needlessly denied coverage and or reimbursement for medically necessary procedures from their health insurance providers," said Curran. "It will enable the Office of the Attorney General and the Insurance Administration to continue assisting consumers who wish to appeal decisions made by their HMOs."

Curran says the Unit has a 70 percent success rate in getting consumers' health insurers to reverse their decision to deny coverage for treatment when they are subject to MIA review. This is compared to a 56 percent success rate when the insurance carrier is not subject to MIA. Health consumers can contact the HEAU for assistance at 1-877-261-8807.

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