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Health Care Costs and Financing

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Most appeals to two of the Nation's largest HMOs to cover emergency care are resolved in favor of patients

A new study of appeals of coverage denials lodged by privately insured enrollees of two of the Nation's largest health maintenance organizations between 1998 and 2000 found that disputes over emergency department (ED) services accounted for about half (52 percent) of post-service appeals at plan 1 and one-third (34 percent) at plan 2. Furthermore, enrollees won more than 90 percent of these appeals.

Nearly half (46 percent) of ED appeals involved weekend, night, or holiday visits to the ED, and 22 percent were children's visits. The average cost for services in dispute was $1,107. The most common general reasons for the ED visits in dispute were symptoms of illness (64 percent), injuries (22 percent), and services related to disease (8 percent). The most common presenting symptoms were abdominal pain, cramps, or spasms (7.6 percent); earaches or ear infections (3.4 percent); and lacerations/cuts (2.9 percent).

In at least 31 percent of appeals at plan 1 and 87 percent of appeals at plan 2, plans reversed the medical group's utilization review denial on its merits. This signals explicit disagreement between plans and medical groups about the appropriateness of ED use.

Consumer protection laws in many States now require managed care organizations to inform enrollees about their rights to internal and external appeals. Nevertheless, rates of appeal are relatively low, and patients almost certainly underestimate the odds that an appeal will yield an overturn, note Carole Roan Gresenz, Ph.D., of RAND, and David M. Studdert, L.L.B., Sc.D., M.P.H., of the Harvard School of Public Health. Their study was supported in part by the Agency for Healthcare Research and Quality (HS11285).

See "Disputes over coverage of emergency department services: A study of two health maintenance organizations," by Drs. Gresenz and Studdert, in the February 2004 Annals of Emergency Medicine 43(2), pp. 155-162.

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