COMMENTARY by Howard Gleckman

BUILDING AN HMO APPEALS PROCESS THAT WORKS

Here's a poll number that's sure to quickly catch the politicians' attention: Nearly two-thirds of voters think protecting patients' rights will be a key campaign issue in November. So, right on cue, President Clinton and Congress have already begun the jousting.

Clinton, who never met a trial lawyer he didn't like, wants to let consumers sue HMOs that refuse to provide care or won't pay its full cost. Republicans, who never met a trial lawyer they did like, want to continue to ban suits against HMOs, but would give consumers limited rights to appeal their decisions.

Appeals make sense, but only if Congress puts some teeth behind them. Federal employees and Medicare HMO patients already have a formal appeals process. But it is a stacked deck. Alas, the GOP plan to expand appeals to all HMO patients loads the deck even more.

Today, insurers can delay decisions for months or even years without penalty. Patients have no right to see HMO documents. They have no due process rights, and most can't find advocates to help them wade through the system. Current appeals are made for HMOs and their legal staffs, not for consumers.

There are ways to make the process work:

--Congress should establish a set of universal guidelines for internal HMO appeals. These should include a board of outside doctors to review disputes.

--Require HMOs to explain the process to their customers, and let them know how many decisions are appealed and how many are overturned.

--Give HMOs hard deadlines to respond to appeals. Today, if patients miss deadlines, they're out of luck. An HMO, on the other hand, can stall for months. If an insurer fails to resolve an appeal within a fixed time, it should lose. Period. If an appeal is denied by the HMO, have the decision reviewed by an independent board. This happens today with Medicare HMOs. But these outside reviewers have limited authority to gather evidence, never hear directly from patients, and can consider only limited issues. A serious appeals process would broaden their authority.

--Give the outside reviewers the power to mediate disputes, a step that would resolve a great many disagreements between HMOs and their patients

--Provide patients the help they need to navigate this quasi-judicial process. One possibility: Require HMOs that lose appeals to pay their customers' legal fees. Medicare now bars patients from collecting such fees, and few lawyers or other advocates will handle their cases.

Gleckman, a senior correspondent in BW's Washington bureau, offers his views frequently on Mondays for BW Online

EDITED BY DOUGLAS HARBRECHT