IN A RECENT decision, the United States Supreme Court ruled that HMOs must follow state laws that afford patients the right to submit for independent review claims denying coverage for medical treatment.

In the case, Rush Prudential v. Moran, the HMO denied coverage for surgery for one of its beneficiaries. The HMO contended that the surgery was not medically necessary. Pursuant to Illinois law, the patient requested that the HMO send her claim out for an independent review, but the HMO refused to do so, saying that a federal law, ERISA, preempted the state law requiring an independent review. The HMO contended that ERISA did not require independent reviews and it did not have to do anything more than what ERISA required.

The United States Supreme Court rejected the HMO’s argument, stating that Illinois law was not preempted by ERISA. The court’s decision means that HMOs are now required to comply with state laws requiring independent reviews of HMO decisions to deny coverage for medical care or treatment.

New Hampshire has a law similar to the Illinois law involved in the Moran case. In New Hampshire, patients have a statutory right to an independent review of the denial of coverage for medical treatment, including drug treatments or prescriptions. To be eligible, the treatment must exceed $400 in a 12-month period. There are some exceptions to the requirement, however. For example, services provided through Medicare or Medicaid do not apply. The process also is not intended to deal with claims of negligence or malpractice.

A request for an independent review is generally made after going through the HMO’s internal appeal process, but a patient and the HMO can agree to submit the claim to an independent review sooner. The request for an independent review is made directly to the New Hampshire Department of Insurance and must be made within 180 days of the date of the HMO’s final decision to deny coverage. The HMO must pay for the review. The independent reviewer’s decision is binding on the HMO. The independent review decision does not prevent the patient from pursuing other avenues of redress (such as going to court).

I have assisted patients and providers through the independent review process and it has worked well for them. It is a relatively quick way to resolve disputes with an HMO (or insurer) over coverage issues that often arise for individuals who may be injured or ill. With the United States Supreme Court decision in Moran, HMOs now have no choice but to abide by the New Hampshire law.

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