WASHINGTON — The Clinton administration, despairing of getting a lame-duck Congress to enact a patients' bill of rights, issued regulations Monday that create a formal and rapid appeals process for 130 million private sector workers.
The process for employees to appeal claims rejected by their health insurance plans until now has varied. The new rules will apply to virtually all companies offering health insurance, with the exception of some small firms. Also exempted are workers in government agencies and church-related groups.
As of Jan. 1, 2002, health plans would have to abide by strict deadlines on notifying patients about coverage. They would have 72 hours to tell patients whether treatments in potentially life-threatening situations would be covered, and 15 days for advance clearance of routine operations. Patients could appeal those decisions to the health plan, which would have to respond within an expedited timetable.
The managed care industry, which often has balked at federal regulation, indicated it would not seek to have the rules overturned by Congress or the next president.
The regulations differ significantly from the proposed patients' bill of rights. That legislation would have created an independent appeal mechanism outside the industry, and would have significantly expanded patients' ability to sue health plans for punitive damages. Currently, lawsuits are restricted to the recovery of medical costs.
For 90% of Americans in managed health care programs, "someone other than your doctor decides if treatments will be covered," said Edward Montgomery, deputy assistant secretary of the Labor Department, which issued the rules. "Too many people wait too long for decisions [and] . . . are frustrated by complicated appeals procedures."
The goal of the regulations is to provide a speedier and more efficient system for handling the contacts between the patients and health plans.
The rules are in three basic categories: medical procedures approved in advance; payment for services and treatments already delivered; and "urgent care" procedures.
For advance certification, such as a gallbladder surgery recommended by a physician, the health plan would have to tell the patient within 15 days whether it will pay for the procedure. If the plan says no, and the patient challenges that rejection, the appeal must be handled within 30 days.
