Obama administration narrows rules for patient health-care appeals

The Obama administration tinkered on Wednesday with recent rules that provide patients more clout in disputes with health insurers, altering the standards in ways that disappointed leading advocates for health-care consumers.

The rules are intended to guarantee patients nationwide the same rights to appeal if their insurers do not cover care that they consider necessary. The federal standards, part of the 2010 law to overhaul the health-care system, replace a patchwork of separate state policies. The rules allow patients to protest to their health plans and, if that does not work, to take their complaints to an outside arbiter.

Health and Human Services officials issued the rules 11 months ago, but they have been working to fine-tune them amid a blizzard of lobbying. Insurers and employers have been urging limited rights to appeal, while consumer groups have been arguing for stronger patient protections.

In the version issued Wednesday , the grounds for a patient to protest an insurer’s decision are narrower than consumer groups have wanted. This is particularly true under a wrinkle in the rules that allows patients to use a federal appeals system if their state does not create its own system — or has a system that does not meet the federal standards.

Specifically, the rule says that patients are allowed to appeal if an insurer declines to pay for care on the basis of a medical judgment. However, patients cannot appeal when the dispute is based, for instance, on mistakes involving diagnosis coding or disagreements about whether a patient should see a medical specialist outside the insurer’s network of doctors.

“Medical necessity is only a small portion of all the reasons why a patient may want to appeal a decision,” said Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network.

In addition, the new version gives patients two months, instead of the previous four, to file a complaint and gives reviewers slightly more time to make a decision. Insurers also will have a new option to hire their own consultants to handle outside appeals, rather than relying on an outside board. And to give states more time to comply with the rules, federal officials will start enforcing the standards in January, rather than next month.

“We view it as a mixed bag,” said Ronald F. Pollack, executive director of the consumer health lobby Families USA. “We think it is an upgrade” from the previous patchwork, which included three states with no appeals systems. “We would have been happier to have them go further.”

Amy Goldstein is a national reporter for The Washington Post focused on health-care policy.
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