[IPp] a good article...read down for the part about insulin pumps
Spitzer Targets Health Insurers
New York Attorney General Threatens Punishment Over Data Sharing
By Jed Seltzer, Reuters
NEW YORK (March 30) - New York Attorney General Eliot Spitzer Tuesday said
health insurance companies have been withholding information from patients
about
how they decide which procedures are medically necessary, and threatened to
punish them if they are not more forthcoming.
Spitzer's office released results of a survey showing that nearly all health
plans violated the law by failing to disclose the criteria they use to
evaluate whether a medical procedure will be covered.
The insurance companies include some of the nation's largest, such as Aetna,
UnitedHealth Group Inc., Cigna Corp., and Oxford Health Plans Inc.
Officials at Aetna and Cigna did not immediately have a comment and
representatives for UnitedHealth and Oxford did not immediately return phone
calls
seeking comment.
The New York Health Plan Association, which represents insurers operating in
the state, said health plans generally do a ''good job providing clinical
review information.'' It said it would work with the attorney general's office
to
help plans raise compliance with the law.
Spitzer said he would not fine the health insurers yet, but he has contacted
them and if they fail to comply, he might seek punishment.
''Our mission is not just punitive. Our mission is to say we want you to live
up to the statutory mandate,'' Spitzer said at a press conference in New
York. ''But we're lawyers, we're prosecutors, we'll do what we need to do.''
Spitzer said his office would negotiate with insurers over an agreement that
would require health plans to more fully disclose their health coverage and
how decisions are made.
''We're saying we'll give you another chance. Not because we love you or we
like you but because it's the right think to do for consumers,'' he said.
The move is the latest among a series of consumer-protection initiatives in
which Spitzer has targeted corporate greed on Wall Street and in the health
care industry, making him perhaps the most high-profile prosecutor in the
United
States.
For the survey, the attorney general's office wrote letters from contrived
customers seeking information about coverage. Each insurer received five
letters
inquiring about coverage for five different medical treatments: insulin pumps
for diabetics, surgery for Crohn's disease, arthroscopic knee surgery,
enteral formulas for people who can't swallow, and breast reduction surgery.
Spitzer's office chose those five areas because they involve procedures that
typically can be performed only after they are declared medically necessary
under objective criteria.
Several letters went unanswered by the health plans, while others elicited
inadequate or incomplete responses.
Only Empire HealthChoice rated a 'B' on a grading scale of A-F. Eighteen out
of the 22 health plans surveyed received either a D or an F.
''The importance of this survey is to stand in the shoes of real consumers,''
said Joe Baker, chief of the health care bureau in the attorney general's
office. ''We're concerned that the plans don't really have any way of complying
with the law.''
Insurance companies were widely criticized in the 1990s for not providing
coverage for procedures that doctors deemed medically necessary and for
discouraging or refusing referrals to specialist physicians.
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