Obama administration narrows rules for patient health-care appeals

[alp227]

Source: The Washington Post

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.

Read more: http://www.washingtonpost.com/national/health-science/obama-administration-narrows-rules-for-patient-health-care-appeals/2011/06/22/AGNciSgH_story.html

[mucifer]

1. that is so sad nt

[No Elephants]

2. I remember his telling stories about how sad it was that his mother spent the last part of her

life arguing with her health insurer.

[ClarkUSA]

3. Is there a more unbiased source other than right wing nut Fred Hyatt's newspaper?

Even the NYT pushed the lie that Al Gore had kicked President Obama to the curb re: climate change when it's clear from Al Gore himself that he did not blame Obama at all; quite the contrary, Al declared himself an Obama supporter and admirer in his Rolling Stones op-ed and complimented the President on everything he has accomplished in a little more than two years.

It's too easy to fall for a MSM whore's line of bullshit in an election year. The Washington Post is no friend of Democrats and definitely no friend of President Obama. Hyatt is a big reason for that.

[FrenchieCat]

4. I couldn't have said it any better.....

strange how folks "trust" the MSM whenever they want to believe the worse. So fucking sick of this bi-polar shit! I don't trust not a motherfucking soul these days....not.a.fucking.one!

[ClarkUSA]

5. Amen to that.

We know the score, don't we? :puke:

[FrenchieCat]

6. We don't have amnesia......

[ClarkUSA]

7. .... like some folks do.

[JDPriestly]

9. Remember how in California we managed to get consumer protection

that permits us leeway in complaining about our health insurance providers.

This will pretty much disable our insurance commissioner. We just elected a strong Democrat as the commissioner. This is a direct assault on his authority. Shame on Obama. This is a stupid thing to do.

[ClarkUSA]

32. Wrong. See Reply #15.

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=102&topic_id=4893404&mesg_id=4893684

[iwishiwas]

10. Well, I hope you do not have a coding error that you can not appeal and

perhaps this is a serious error and you are doomed--or your family member.

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.......

[ClarkUSA]

33. I'm not concerned because I see through WaPo right-wing nut spin. See Reply #15.

Consumer group: "We think it is an upgrade"

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=102&topic_id=4893404&mesg_id=4893684

[JDPriestly]

8. Is the Obama administration serving us or the health insurance companies?

I ask that quite seriously because I think I recall that Michelle Obama worked for a hospital before Obama was elected. Does anyone else remember that factoid?

[somone]

12. Yep. $310K+/yr vice president of a Chicago hospital.

[JDPriestly]

27. She is young. What do you want to bet she will work for a health insurance

company when she moves out of the White House?

And Obama? He will give speeches to big corporations for huge, bloated overpayments. That is how the Clintons amassed their fortunes.

Oh, and of course books -- books that we Democrats will dutifully and gratefully receive in lovely Christmas wrappings with bows on top. I think I will warn everyone before they do their shopping.

[tpsbmam]

15. You even have to ask?

The corporate puppet services the corporate puppeteers.

And, yes, I remember Michelle's job. I think what's really pathetic is his recalling what his mom went through with health insurance companies (as someone noted upthread) and his craven willingness to make sure each and every one of us gets the same crappy treatment as his mother did. Of course HE, nor anyone in his family or the legislators who gave us this crap or their wealthy cronies will suffer through this -- it's okay with them if we do as long as it doesn't affect them.

I see cutesy pictures on DU of the Obamas with the kids, Obama getting a photo-op with a patient, Obama golfing with banking CEOs....and I can't stand looking at them. I've gone from being a campaign volunteer/contributor/GOTV volunteer to being thoroughly disgusted. When he gives speeches now, I turn the TV off. I know I can read the speech the next day and frankly, I know it'll be full of bullshit and will just irritate the shit out of me to watch & hear him spout more of his eloquent lies.

It all makes me sad. And really, really pissed off.

[CountAllVotes]

20. You are right!!!!

:hi: btw long time no see!

:kick: & recommend

[tpsbmam]

46. I've been in hiding....

alternately furious and fighting and then ignoring the world and watching movies or reading. Right now, I'm reading the Rise & Fall of the Third Reich, which is giving me the creeps in the similarities to the USA today!

Hope all is well!

:hi:

[Carolina]

23. love your post and your avatar, tpsbmam

and couldn't agree more with your words:

"I see cutesy pictures on DU of the Obamas with the kids, Obama getting a photo-op with a patient, Obama golfing with banking CEOs....and I can't stand looking at them. I've gone from being a campaign volunteer/contributor/GOTV volunteer to being thoroughly disgusted. When he gives speeches now, I turn the TV off. I know I can read the speech the next day and frankly, I know it'll be full of bullshit and will just irritate the shit out of me to watch & hear him spout more of his eloquent lies."

Pisses me off royally!

:hi::hi:
:hi::hi:

[tpsbmam]

47. Thanks, Carolina!

Are we neighbors (given your name)?


:hi:

[ClarkUSA]

35. The answer is "us". Read the truth, not right-wing MSM headlines designed to fool you.

Consumer group: "We think it is an upgrade"

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=102&topic_id=4893404&mesg_id=4893684

[stockholmer]

11. so, what else is new?

:puke:

[placton]

13. As another post said, these Dems (?) are the 3rd wing of the GOP

I think Obama is gonna be horribly surpised by the votes he DOESN'T get next year.

[Joe Bacon]

14. Chalk up another win for the pimps running the insurance rackets.

Once again, Obama comes down on the side of Wall Street.

And today I got another letter from his re-election campaign asking for money. Went straight to the shredder. This time I won't drop a single penny into Obama's pocket. I will give to REAL Democrats like Sherrod Brown and Bernie Sanders.

[Carolina]

24. rather than shred, send it back,

especially if it's postage paid, with comments on it about how disgusted, disappointed, etc you are and why. I include posts from DU, articles from other websites, etc. and a message saying I don't have any money thanks to his GWB III term and my health INSURANCE (not care)premiums!

[ieoeja]

16. Consumer group: "We think it is an upgrade"

"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."

[Divernan]

17. Wash. Post lays out cold hard facts which Obama supporters here cannot dispute

"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."
***********************************************************************************************************************

This is a good example of the power the Obama administration has to effect change through regulations. So since the administration's ardent supporters here cannot blame the Congress, and they cannot deny the facts of the regulatory change, they resort, as in post 3 above to likening the Washington Post & New York Times as mainstream media whores.

They cannot dispute the facts of the report which state:
(1) Obama cut back the time in which a patient can appeal a decision from four months to TWO MONTHS. Those of you who have dealt with serious illnesses of yourself or a family member, know that someone elderly, someone poorly educated, someone in great pain, or dealing with the likes of chemotherapy, for example, easily falls behind on the vast amount of paperwork sent to consumers by Medicare, Medicaid, private insurers, hospitals, labs, physicians, etc. Many elderly people have no one to help them in making heads or tails of this tsunami of paperwork. I think consumers should have a year in which to take an appeal.
(2) Patients lost the right to appeal for anything other than medical necessity, such as a mistake made by some bureaucrat in diagnosis coding, or whether a patient can access a medical specialist outside the insurer's approved list of doctors.
(3) While patients are given less time, those making the decision are given more time, i.e. delaying whatever treatments the insurers may eventually have to pay for. As Michael Moore pointed out, and as I observed in my legal practice, Big Health Insurers routinely denied coverage for major treatments knowing full well that by the time the insureds managed to jump through all the appeals hoops, odds are many would have died.
(4) And mind-boggling as it is, insurers will now have the option of hiring their OWN consultants to handle appeals, rather than relying on an outside (read independent) outside board.

I think it's time for Michael Moore to do a sequel to "Sicko".

Who benefitted from these changes? Big Health Insurance.

[Doctor_J]

18. #4 is particularly disgusting

These robbers policing themselves has been a hallmark of the corporate terrorism the last couple decades.

[ProSense]

19. This is a perfect example

of the ACA being misrepresented in its original form. A lot of people gave up on it and industry lobbyist had the louder voice.

Implementing Health Reform: The Appeals Process Amended Rule

<...>

The initial rules were quite strong, expanding on the protections offered by the existing ERISA internal review regulations and establishing a binding, impartial, external review process. Almost from the beginning, however, the three agencies that issued the regulation (the departments of Health and Human Services, Labor, and the Internal Revenue Service) began to waffle in the face of intense lobbying from insurers and employers, delaying enforcement of some of the internal review provisions by a technical guidance issued in September of 2010 and again by another issued in March of 2011, and weakening the federal external review procedure in a September 2010 guidance.

On June 22, 2011, eleven months after the issuance of the initial rules, Treasury, Labor, and HHS released amendments to the interim final rule accompanied by further guidance which together significantly undermine the consumer protections found in the initial rule. Although the amendments do address some real practical difficulties that were encountered in implementing the initial rules, they also represent a movement away from the aggressive consumer protection stance represented by the earlier ACA rules toward a position more accommodating to the needs and desires of insurers and employers. Consumer advocates lost to industry on virtually every issue addressed by the amendments and guidance, although in some instances changes were softened to address consumer concerns.

<...>

The good news is that these may be temporary, Kaiser:

<...>

Some of the limitations in external appeals may be removed in 2014 when other consumer protection provisions of the health law take effect and the marketplace has had "time to adjust to providing external review," the regulation says.

[Divernan]

21. Kaiser link reminds Big Insurance to keep up lobbying pressure/political donations till 2014

The info in your post re: Kaiser, notes that the regulation states some of the appeal limitations MAY be removed in 2014.

First, let's have a moment of silence for all the people who will die and/or go bankrupt at the hands of Big Health Insurance between now and then.

Second, speaking as a retired lawyer whose last 10 years' work was as a staff attorney for a state legislature's Democratic caucus, this language was included by the Administration, and quoted by the Kaiser group, to remind Big Health Insurance to make sure their lobbyists keep up the political pressure, i.e., campaign donations, to the elected official who appoints the top bureaucrats/cabinet secretaries of the three agencies, Health & Human Services, Treasury & Labor.

[ProSense]

25. It's

rather interesting how offended people are by a rule-making process on a bill they have no use for.

Maybe there can be a lot of push back to ensure that "may" becomes "will."

Seriously, the process has been ongoing since the bill was signed into law, and none of its critics gave it a thought except to call for its repeal.

[Divernan]

30. We elect our president to represent our interests via administrative agencies

What are you referring to in such a vague manner? WHO had no use for a bill? So no one has a right to be offended when three administrative agencies under the control of Obama's appointees weaken consumer protections of seriously ill consumers? So from now until 2014, all those who are now or may in the future be ripped off by their Big Health Insurer should hie themselves to Washington and lobby federal agencies? And if they don't do so, they have no standing to complain if these anti-consumer interpretations/applications are not reversed?

For future reference, in case you're oh so subtly implying that I am one of those you refer to as having no right to be offended by or have any use for "the bill", whatever uncited bill you are referring to, I have been fighting with health insurance companies, pro bono, on behalf of a number of people - at least two of whom thanked me for saving their lives. Just yesterday, I was back and forth on the phone between a pharmacy and a private health insurer which wanted to postpone paying for an IMMEDIATELY required drug, on the grounds that there was an error in the way the prescription was processed - the wrong code. Because the Insurer knew it was dealing with a lawyer knowledgeable about health insurance policies, I was able to get the matter resolved in 2 hours. How many consumers have a lawyer friend to go to bat for them for free? You have a name and number in the White House for them to call?

So seriously ill individuals who have purchased private health insurance are expected to go head to head with Big Health Insurance lobbyists to protect the integrity of regulations which were already in place?

Drafting and implementing regulations is the job of the Presidents' administrative agencies, and the individuals whom he appoints to run those agencies. Please explain to me your understanding of how the lobbyists "pressured" those agencies. I've attended many a hearing on legislative/administrative matters. Corporate lobbyists NEVER, I repeat NEVER simply appear to testify on such matters. They show up with polished drafts of the changes which they propose to a law or regulation, in one hand, and a campaign donation/bribe in the other hand. In the case of legislators, the lobbyists can hand their checks directly to the legislator. In the case of regulatory agencies, the checks go to the governor (state matters) or president (federal matters), albeit indirectly via a campaign committee.

Surely, you do not mean to argue that individual citizens have an obligation to familiarize themselves with the complex and arcane ins and outs of federal regulations. That's what we have representative government for - in the sense that government is of, by and for THE PEOPLE, not of, by and for corporate lobbyists.

[ProSense]

37. Wait

who proposed the initial rules? Have you heard from the administration about the justification for altering its own rules?

"So from now until 2014, all those who are now or may in the future be ripped off by their Big Health Insurer should hie themselves to Washington and lobby federal agencies? And if they don't do so, they have no standing to complain if these anti-consumer interpretations/applications are not reversed?

<...>

So seriously ill individuals who have purchased private health insurance are expected to go head to head with Big Health Insurance lobbyists to protect the integrity of regulations which were already in place?"

Where are you getting that from?

Here are the changes



As the articles posted in this thread point out, some were justified to address consumer group concerns, a few are disappointing, and they may be reversed.

Certainly, Consumer Watchdog and other groups are going to continue pressuring the administration.

[Divernan]

39. In answer to your question, no I have not heard from the Administration.

Where did I get my questions to you from? From struggling to understand how you rationalized your criticisms of those of us who criticized these regulatory changes.

Aside, speaking as someone from Pittsburgh, and a longtime Steelers fan, Hines Ward has got nothing on you!

[ProSense]

40. Hmmmm?

"From struggling to understand how you rationalized your criticisms of those of us who criticized these regulatory changes."

It's called disagreeing with you and presenting another opinion.

[Divernan]

44. I presented facts, you presented your opinion.

[JDPriestly]

31. Actually, I did a lot of research on this a few years ago.

It was Scalia who wrote the dastardly decision Mertens (among others). Here is a paper on this topic. I did not write the paper cited below.

http://digitalcommons.law.yale.edu/cgi/viewcontent.cgi?article=1484&context=fss_papers&sei-redir=1#search=%22Scalia+decision+ERISA+1995%22

That decision mean that if you are insured by work-related insurance, and you lose a child because benefits are denied, you cannot sue for monetary compensation from your insurance company. And so the appeal process to try to get the services you are owed by contract, you have to file a complaint and beg.

This is a merciless system, and Obama has just added to the misery of people who need medical care, let's say for their seriously ill child, and are denied by the insurance company. This is an inhuman cruelty. Not many people have to deal with a situation of that nature. But when health care reform was being discussed, we heard story after story of people who were denied care they had paid for. Congress tried to correct this problem. Obama's huge "mistake" (I question whether it was accidental or intentional) was to permit the delay of the implementation of his health care reforms. It was yet another betrayal by this man who lacks the strength of moral courage to face down evil when he meets it.

[JDPriestly]

28. This is horrible. In California, we had a referendum and brought in

rules that allow generously for appeals. This is how the insurance companies are pre-empting our California rules.

This is dirty politics. Obama has struck liberals again. This will backfire on Obama as Californians lose their rights thanks to his rulemaking. And this is an Obama stronghold. What a bad political move. How stupid can you get. An opt-out for state rules that are more accommodating to patients would have solved this injustice. Such a simple thing, but so far beyond the Obama administration.

[BlueIris]

26. Nasty. Really, really nasty. nt

[ClarkUSA]

36. I dispute WaPo's right-wing spin. Read the opinion of this consumer group. They dispute it, too.

Consumer group: "We think it is an upgrade"

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=102&topic_id=4893404&mesg_id=4893684

[Divernan]

45. The WaPo is your source for your quote. So is your quote right wing spin?

You're chasing your tail, sweetie!

[Divernan]

22. American Cancer Society & other patient's advocacy group decry changes.

Stephen Finan, senior policy director at the American Cancer Society Cancer Action Network, said Wednesday's announcement would have the opposite effect. "Transparency and independence are critical to ensure that a fair and objective appeal is conducted," he said. "Unfortunately, there are numerous barriers and burdens placed on the consumer that could prevent a timely and objective resolution to a denial."

"My greatest disappointment is the narrowing the scope of external review," said Jennifer Jaff, executive director of Advocacy for Patients With Chronic Illness, a nonprofit group in Farmington, Conn., that handles about 750 health insurance appeals a year. "The regulation imposes a new fuzzy standard."

This standard limits external appeals, said Finan, to decisions based on "medical judgment." That restriction "would fail to address a significant proportion of denied claims based on other factors such as coding errors and failure to receive pre-authorization," he said.

In addition, consumer groups are concerned that limiting information insurers have to provide about why a claim was denied will require beneficiaries to seek additional explanation if they want to appeal.

http://www.kaiserhealthnews.org/Stories/2011/June/22/External-Appeals-Reg-Jaffe.aspx

[ClarkUSA]

42. Here are some important aspects of the proposed changes that have escaped attention...

However, some important consumer protections that advocates were concerned about remain intact. Decisions by external review panels are binding and patients can still appeal if their insurers cancel their coverage. Employer-sponsored plans that are self-insured will have to use at least two independent review organizations to help assure impartial decisions.

Since states do not regulate self-insured health plans, there has been no requirement allowing those beneficiaries to appeal denials to an independent review panel. The health law extends that right to more than 44 million Americans covered by self-insured plans that have lost their "grandfathered" or exempt status this year.

"The right to an external appeal is considered one of the most important consumer protections that you can have," said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight at the Department of Health and Human Services. "Consumers do not want insurance companies making medical decisions for them or for their families."

Yet Larsen said states would have more time to revise the patchwork of local external appeals rules so that they can conform to the federal standards. Insurers won't have to comply with new state rules incorporating federal requirements until Jan. 1, instead of next month as originally proposed.

http://www.kaiserhealthnews.org/Stories/2011/June/22/External-Appeals-Reg-Jaffe.aspx

[woo me with science]

29. Oh for fuck's sake.

There is a new betrayal every day. Every goddamn day.

[ClarkUSA]

34. There is a new misguided outrage every day based on believing right-wing MSM whores. See Reply #15.

Consumer group: "We think it is an upgrade"

"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."

http://www.democraticunderground.com/discuss/duboard.php?az=show_mesg&forum=102&topic_id=4893404&mesg_id=4893684

[Divernan]

38. Funny you choose to rely on a quote from the Washington Post.

So the Post is MSM whore in those parts of a report which criticize Obama, but a source you quote when it suits you.
Further, you gave only a mis-representative part of a quote from a consumer group.

The entire paragraph stated:
“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.”

Now would you be so kind as to enlighten us all on what specific changes were "upgrades"? Then we all, being thinking people, can compare the costs and benefits to Big Health Insurance of the changes.

[ClarkUSA]

41. No, my quote is from the head of a consumer group who disagrees w/the OP's WaPo bullshit headline.

If you have any questions regarding what Mr. Pollack said, refer them to him. I have no such burning need. Contact info is easily Googled. :)

[Divernan]

43. Your quote is from the WP article. No other cite. Ergo, you rely on the accuracy of the WP.

Further, it does not refer to one single, solitary instance substantiating a vague statement that changes were an upgrade for consumers. You're the poster citing Pollack as supporting your position, yet offer not a single fact upon which Pollack relies. The burden of proof is on you, sweetie!