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HMO Reviews Should Not Involve Contracts

January 08, 2002

The Times' Dec. 24 editorial embracing consumer appeals of health plan decisions overlooks the serious implications of allowing a state agency to rewrite health-care contracts. Blue Shield of California established California's first voluntary external review process six months before the state Independent Medical Review process was created. The IMR process enables consumers to appeal a health plan's decision only to determine whether a treatment is medically necessary.

In the case you cited, however, Blue Shield did not pay for the weight-loss drug because it was not a covered benefit under the plan chosen by the consumer. If the Department of Managed Health Care forces health plans to pay for treatments that are expressly not covered by their state-approved contracts, plans would be exposed to unlimited financial risk for costly treatments that were never considered in pricing the coverage. As a nonprofit health plan, Blue Shield is obliged to challenge this decision to secure our ability to pay the bills for 2 million members who need services that are covered under their contracts.

Jeffrey Rideout MD

Chief Medical Officer

Blue Shield, San Francisco

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