Politics & policy

Insight into federal and state health care legislation & CMS regulation

Wisconsin Bills Aim at Denials Of Coverage

Two bills introduced in the Wisconsin Legislature would expand the rights of patients when dealing with physicians and plans. The bills, which are similar, were introduced by Rep. Frank Urban, a physician, and Sen. Carol Roessler, both Republicans.

Under the proposals, prior authorization would not be needed for emergency services if a "prudent lay person" would conclude that the emergency was serious enough to require a trip to the hospital. Health plans that deny claims would be required give patients written explanations of denials of coverage, along with instructions for pursuing appeals.

Plans would have to offer a point-of-service or similar option so members could see non-plan physicians, and would also have to provide ways for new members to continue to see their current physicians — even those not in the plan — as long as they like.

Plans would have to reveal details of physician payment and incentives, coverage, premiums, deductibles and prior payment authorization, while guaranteeing public access to enrollee-satisfaction statistics.

Finally, the state insurance commissioner would appoint a task force on standards for certifying health plans. Current regulations focus on plans' financial status, not on questions concerning provider panels or patient care issues. The task force would expand the certification review process to include these issues.

Health plans say many of the bills' provisions are already state law, and that further regulation would drive up health care costs. The state medical society supports the measures.

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