Patient Advocacy
”American consumers deserve to know what they’re getting when they pay their health insurance premiums. They’ve been in the dark for too long.”
John D. (Jay) Rockefeller IV, Chairman, Senate Committee on Commerce, Science, and Transportation
For purposes of this Section, “to advocate for medically appropriate health care services” means to appeal a decision to deny payment for a health care service…”
Managed Care Reform and Patient Rights Act. (215 ILCS 134/35)
Managed Care Reform and Patient Rights Act. (215 ILCS 134/35) Appeal Is Compliance, Not Trouble-making
Sec. 35. Medically appropriate health care protection. (a) No health care plan or its subcontractors shall retaliate against a physician or other health care provider who advocates for appropriate health care services for patients. (b) It is the public policy of the State of (most all) that a physician or any other health care provider be encouraged to advocate for medically appropriate health care services for his or her patients. For purposes of this Section, “to advocate for medically appropriate health care services” means to appeal a decision to deny payment for a health care service pursuant to the reasonable grievance or appeal procedure established by a health care plan or to protest a decision, policy, or practice that the physician or other health care provider, consistent with that degree of learning and skill ordinarily possessed by physicians or other health care providers practicing in the same or a similar locality and under similar circumstances, reasonably believes impairs the physician’s or other health care provider’s ability to provide appropriate health care services to his or her patients.”
WASHINGTON, D.C. – The Senate Committee on Commerce, Science, and Transportation held a full committee hearing today on “Deceptive Health Insurance Industry Practices– Are Consumers Getting What They Paid For?”
The health insurance industry has been promising to pay a certain share of consumers’ medical bills, but then they have been rigging health charge data to avoid paying their fair share,” Rockefeller said. “The result is that billions of dollars in health care costs have been unfairly shifted to millions of American consumers.”
• “Nationwide, medical costs are the leading cause of individual bankruptcy, even though the individual usually had insurance,” testified Linda Lacewell, representing the Office of the New York State Attorney General. “Fraudulent under-reimbursement for insured Americans is one part of this negative equation for consumers.”
Statements from the New York Attorney General, Mr. Cuomo’s office also included in subsequent reporting;
“the industry had engaged in “a scheme to defraud consumers” by systematically underpaying the nation’s patients by hundreds of millions of dollars over the last decade. “
The report of the investigation’s findings described the industry calculations as “created in a well of conflicts” that produced information that was “unreliable, inadequate and wrong.”
“This is like pulling back the curtain on the wizard of Oz. We have now shown that for years consumers were consistently low-balled to the tune of hundreds of millions of dollars.”
“Insurers need to give the money they were contractually obligated to give,” he said. “This is the most basic consumer protection I can think of — you have to do what you’re contractually obligated to do.”
“Seventy percent of insured working Americans pay higher premiums for insurance plans that allow them to use out-of-network doctors”.