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Lack of Action On Appeals Law Puzzles Texans

MANAGED CARE May 1998. © MediMedia USA
News and Commentary

Lack of Action On Appeals Law Puzzles Texans

MANAGED CARE May 1998. ©1998 Stezzi Communications

Texas officials are not sure what to make of a lack of interest in a state law governing appeals of denial of care. The statute allows health plan enrollees to petition an independent state commission for review of denials after they have exhausted their insurers' internal appeals processes. Since the law giving Texans that right passed last summer, however, only 16 cases have been put before the state — far fewer than the 4,000 requests it expected during the first year.

Health plans have an answer. They say the fact that little has happened is testament to their efforts to improve appeals processes. Texas Medical Association executives, too, think many plans have changed their procedures, but to avoid the expense of external review. Still, the state's HMO industry is challenging the law in court.

The legislature passed the bill after a number of patients testified about having been denied medical care. Texas is one of only nine states to mandate external review. Because most managed care reform plans in Washington include provisions for external review, the industry is watching Texas carefully. To date, the commission has upheld insurer denials six times and overturned eight others. Two are pending.