2 Federal Courts Differ Concerning External Appeals


Almost 40 states have laws giving health plan members the right to seek external review of denials of coverage. Conflicting federal court rulings about states' authority to bind health plans to external review decisions have put their constitutionality in question.

The U.S. Court of Appeals for the Fifth Circuit last June tossed out the external review provision in Texas's right-to-sue law. Health plans, most of which welcome external review as an alternative to a day in court, offer it along the lines of the now-invalidated state law — though are not required to.

Last month, an Illinois external review law nearly identical to the Texas provision was upheld by the Seventh Circuit Court of Appeals. The legislature, the court ruled, merely sought to provide unbiased, third-party arbitration when HMOs and physicians cannot agree on treatment.

Several legal experts told the Dallas Morning News that the two decisions are squarely opposed, and that the question will have to be resolved by the U.S. Supreme Court.

Career Opportunities

HAP, a subsidiary of Henry Ford Health System, is a nonprofit health plan providing coverage to individuals, companies and organizations. This executive develops strategies to meet membership and revenue targets through products, pricing, market segmentation and advertising.  Aligns business among Business Development, Commercial Sales, Medicare and Public Sector Programs and Product Development. Seeks to enhance and be responsible for business development and expansion through the development of an effective product portfolio, strong interpersonal relationships and service excellence.

Apply via email to jfedder1@hfhs.org or online at http://p.rfer.us/HENRYFORDlXqAJA

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