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ACP-ASIM Pressroom

ACP-ASIM Urges Defeat of Amendment to Let Insurers, Not Doctors, Determine Medical Necessity

June 26, 2001

Amendment to Create Safe Harbor for HMO's Leaves Patients At Sea

(Washington, DC) Key consumer protections included in the Bipartisan Patient Protection Act of 2001 (BPPA) are being attacked by an amendment that would continue to protect a managed care organization's (MCO) right to deny patients necessary treatment without being held accountable for its actions.

"One of the key protections offer by the BPPA is that treatment decisions will be based on the best evidence the medical community has available," said William J. Hall, MD, FACP president of the American College of Physicians - American Society of Internal Medicine. "Preventing insurers from making medical decisions without being accountable for the results is at the core of patient protection."

Currently, BPPA calls for an external review board of medical experts to review a patient situation and current scientific literature and decide whether or not an MCO unfairly or inappropriately denied coverage for a medically necessary treatment.

An amendment, expected to be introduced this week, will offer alternatives that continue to allow insurers to determine treatment standards without being held accountable to independent review. One alternative provides a safe harbor to any insurer that follows its own standards of medical necessity, regardless of whether those standards would stand up to outside scrutiny. Another creates a national standard through the use of either a Blue Cross/Blue Shield definition of medical necessity or creation of a definition through administrative rule-making. (Under administrative rule-making, the insurance industry could block any national standard to which it objected).

"MCO's have been creating their own definition of what treatments are necessary and it doesn't work," stated Hall. "That's why laws have been enacted to guarantee a patient with chest pain can go to the emergency room for an EKG or a woman can stay in the hospital for two days after giving birth."

The College continues in its commitment to the BPPA bill as it includes the key elements the organization believes should be included in a patient bill of rights:

  • An effective, independent and timely appeals mechanism for patients that are denied access to needed services as determined by professional standards of medical necessity backed by clinical evidence, not by the insurance industry's own restrictive definitions
  • The right of individuals to hold managed care plans accountable for decisions that have harmed them or their family members in a way that will not expose employers to liability for health plan determinations made by insurers-or open up health plans to unwarranted lawsuits and excessive damages.
  • Guaranteed choice of physician and access to specialty care.

ACP-ASIM is the nation's largest medical specialty organization and the second largest physician group. Membership encompasses more than 115,000 internal medicine physicians and medical students. Internists are the major providers of medical care to adults in America.

Jack E. Pope, ACP-ASIM Washington Office, 202-261-4556

Page updated: 11-04-03

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