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Consumer Watchdog to Congress: Put Patients' Bill of Rights Back on the Table
Date:6/4/2009

ted." Under the Employee Retirement Income Security Act (ERISA) and the Pilot Life decision, lawsuits are removed to federal court where victims can only recover the cost of the procedure or service denied in the first place -- no damages or penalties are allowed. As a result, HMOs and insurers are largely free to deny access to care without fear of reprisal or financial consequences. Any health care overhaul should overturn Pilot Life and restore the reach of state common law.
  • Refusing access to expensive doctor recommended medications and devices. HMOs and insurers often refuse to authorize and pay for "off-label" use of expensive medications used to save cancer patients even though there is substantial evidence of their efficacy. For example insurers have routinely denied the use of Avastin for ovarian cancer even though it has been proven highly effective. State-of-the-art prosthetic devices are routinely denied as not "medically necessary." The lack of financial consequences for HMOs that refuse to defer to doctors encourages these practices.
  • Balance billing and Network Restrictions. Many Americans have been surprised to receive a bill from an emergency room doctor after receiving emergency treatment. The problem is that physicians who are not part of the injured person's HMO or insurance network are unsatisfied by the insurance company's low payment for treatment. The practice of physicians sending an additional bill to the patient to make up the difference between what the insurer paid and what the doctor believed was the fair cost of the service -- known as "balance billing" -- is rooted in the problem that insurance companies refuse to pay fair rates. A recent lawsuit settled by New York Attorney General Andrew Cuomo found that health insurers grossly underestimate so-called "customary and reasonable" payments for PPO care, which leads physicians to send the large balance of the bill to patients.

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    SOURCE Consumer Watchdog
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