Governor signs patients rights bill

Posted: Sunday, June 04, 2000

JUNEAU (AP) --A bill that gives Alaskans rights in medical disagreements with insurance companies was signed into law Thursday by Gov. Tony Knowles.

Rep. Norm Rokeberg's ''Patient Bill of Rights'' sets out new appeal procedures when patients are denied requests for services.

''The idea is to increase quality of care and freedom of choice and minimize the frustration people have in getting preapproved for procedures,'' said Rokeberg, R-Anchorage

However, Rep. Eric Croft, D-Anchorage, said the bill falls short of a comprehensive resolution to questions surrounding managed care.

''The fundamental issue in health reform is what happens when a doctor says a treatment is medically necessary and the insurance company says it will only pay for a cheaper, less effective alternative,'' Croft said.

Croft said early versions of the bill attempted to address the ''medical necessity'' question but the final version favors insurance companies over doctors and patients.

Rokeberg said the medical necessity question has been disputed by insurance companies and medical associations for more than 30 years. He said the new law's claims review process incorporates elements of the debate, such as standards of care in a community, and gives patients a way to overcome denials.

He said the new law addresses an issue that has frustrated many Alaskans: preapproval of benefits, in which insurance companies require a call before they agree to pay for a medical test or service.

Under the law, patients denied a service have the right to an internal appeal. The appeal must be reviewed by an insurance company employee holding the same professional license as the patient's health care provider. In other words, Rokeberg said, if a patient's doctor orders a test and preapproval is denied, the appeal must be reviewed by an insurance company doctor, not a nurse, physicians assistant or other company employee.

''They have a better understanding of the diagnosis of the case,'' Rokeberg said.

If a claim is denied internally, the law requires an external claims review procedure. Claims must be reviewed by an independent panel, under contract with the insurance company, of at least two physicians or specialists. Patients must have an answer within 21 days of filing their appeal.

''The two-step internal review mechanism and the third-party external review appeal procedure gives the average person an opportunity to have a fair and impartial hearing of whether or not the disputed benefits should be paid,'' Rokeberg said.

For insurance policies that cover emergency services, the law sets up a ''prudent person'' standard. Policies must cover emergency services that a layman would say was necessary, Rokeberg said.

The law prohibits insurers from limiting a patient's choice of doctors, Rokeberg said, although using a physician outside a company's list of providers could mean an increase in the patient's premium.

The law also prohibits financial incentive clauses between insurers and doctors that reward doctors for not recommending expensive procedures.

The law also:

--Allows physicians to advocate for their patients without risk of penalty or termination by the managed care company with which they contract.

--Prohibits ''gag clauses'' that deny health care providers the right to inform patients of all treatment options.

--Requires coverage of services in another community if a medical service is not available in a patient's home town.

--Requires health plans to describe which prescription medications are covered and which are excluded.

--Requires health plans to describe available translation or interpreter services.

Insurance companies could face civil liabilities for violating provisions of the law.

The bill takes effect July 1, 2001.

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