With many people predicting passage of third-party-review and prudent-layperson legislation this year, some health plans may be forced to improve efforts to educate members about their own rules and procedures. A handful of HMOs surveyed by InterStudy Publications do not have written definitions of medical necessity that are applicable for dispute resolution, and more than a quarter do not make expense or benefit data for representative conditions available. Given that, it doesn't require a big leap to understand why the most common disputes HMOs faced in 1997 were related to rules — not diagnoses. One curious finding: While 95 percent of HMOs have a prudent-layperson standard for ER coverage, ER-claim denial was one of the most frequently appealed problems by HMO members.
SOURCE: HMO INDUSTRY REPORT 9.1, INTERSTUDY PUBLICATIONS, MINNEAPOLIS, 1999