The Government Is Pushing. More To Come -- no matter Bush or Gore. Everybody knows it.
Company Health Plans Have Less Time To Respond to Patients' Claims, Appeals
By LAURIE MCGINLEY
Staff Reporter of THE WALL STREET JOURNAL
WASHINGTON -- The Clinton administration set tighter deadlines for company health plans to respond to insurance claims and appeals filed by patients.
The regulations, which are being published in Tuesday's Federal Register, aren't nearly as sweeping as White House-backed patients' rights legislation that died in Congress this fall. For example, the rules don't give patients who are denied care the right to sue for damages -- something that can only be conferred through legislation.
But the rules, two years in the making at the Labor Department, represent the first change in federal regulations on claims processing and appeals since they were adopted more than two decades ago. They apply to plans, covering more than 130 million people, that are governed by the Employee Retirement Income Security Act.
In a statement, President Clinton said the regulations represent his final effort to improve patients' rights. But, he said, because the administration's authority is limited, legislation is "the only way to give every American in every health plan the right to see a specialist, to go to the nearest emergency room -- not the cheapest -- and to hold health-care plans accountable when they cause harm" by denying care.
Under the old rules, initial health claims from employees had to be processed within 90 days. The new rules shorten that period to 72 hours for "urgent-care claims" and 15 days to 30 days for most other claims. Under the old rules, appeals on denied claims had to be decided in about 60 days. The new rule requires decisions within 72 hours in urgent-care situations and 30 to 60 days for most other claims. In addition, the rule also triples -- to 180 days -- the amount of time that employees have to file appeals on denied claims.
The Labor Department estimated that the rule will cost group health plans $103 million in 2001 in start-up costs and $379 million a year beginning in 2002.
The Health Insurance Association of America, an industry group, sharply criticized the regulations, saying the increased costs will prompt some companies to drop health coverage for workers and their families. But the American Association of Health Plans, which represents more than 1,000 managed-care plans, said the rules were less onerous than those proposed last year. Karen Ignagni, president of the group, said the rules were "a step forward," but said she remains concerned that the regulations might encourage increased litigation against health plans and employers.
The rule also requires employer-sponsored plans to disclose to workers more information about what is covered, and what isn't, and the costs involved. |
