Top Court OKs Medical 2nd Opinions

By TAMMY WEBBER, Associated Press Writer Fri Jun 21, 3:39 AM ET CHICAGO (AP) - When Debra Moran's insurer refused to pay for an operation to treat her debilitating nerve problem, she didn't take no for an answer. She got a second opinion. When her HMO still wouldn't pay even after an outside reviewer found the operation medically necessary, Moran footed the $94,000 bill by borrowing money and maxing out her credit cards. Then she went to court. Moran's desire to be reimbursed swayed the Supreme Court on Thursday in a decision that potentially affects more than 70 million Americans whose employers buy coverage from a health insurance company. The court ruled that states can require health plans to accept an outside, second opinion when there is a dispute with a patient over paying for care. "I really shows that if you're adamant about your position, the justice system works for you," said Moran, who hopes the ruling encourages other patients to seek second opinions. "They need to know the laws are out there," she said. Independent reviews are not frequently sought. In 2000, about 2,500 cases were accepted for full review in 16 states surveyed by the American Association of Health Plans. The reviewer upheld the decision made by the insurers' doctors in about half of those. Health care advocates say one reason for the low numbers is that people are unaware of the option. That could change with the attention from Moran's case. Moran's health problems began in 1995. Physical therapy and other treatments recommended by her primary care doctor did not relieve her arm pain, so she sought the opinion of a surgeon who did not participate in her health plan. That doctor recommended a more extensive surgery, for which Rush Prudential HMO Inc. refused to pay. The Supreme Court's 5-4 vote affirms a ruling by the U.S. 7th Circuit Court of Appeals in Chicago, which said under Illinois law, Moran was entitled to both the review and the reimbursement. The court also endorsed similar laws in 41 other states intended to let people get second opinions, and sometimes force health maintenance organizations to pay up if an independent review shows a surgery or other care is justified. The court said that state laws, in trying to better arm patients in their battles with big managed-care companies, did not contradict a confusing 1974 federal law. Justice David H. Souter, writing for the majority, said that when an HMO guarantees "medically necessary" care like Moran's company did, states can allow an independent reviewer to look at the necessity. Dissenting Justice Clarence Thomas said the ruling "undermines the ability of HMOs to control costs, which, in turn, undermines the ability of employers to provide health care coverage for employees." Moran, of Winfield, Ill., said she knew the vote would be close. "It's been a long time," said Moran, who filed a lawsuit in 1998. "The champagne's been in the refrigerator a long time." Ron Pollack, president of Families USA, a liberal group that has been lobbying for a federal patients' rights bill, said the ruling could affect 70 million Americans. It does not help the estimated 60 million people whose employers use self-insured plans. Employers and insurance companies said the decision would increase the cost of coverage. HMOs had argued they were not opposed to independent review boards but wanted one national standard instead of the hodgepodge of state laws. "By forcing employers and health plans to adhere to potentially 50 different conflicting state external review requirements, the court has dealt them a blow in the battle to control the already soaring cost of health care for working families," said a statement from the Health Benefits Coalition, a group of businesses. The American Medical Association said the decision "represents a major victory for America's patients and their physicians." The ruling also lifts some pressure from Congress, which has failed to pass a national patients' rights plan calling for a nationwide system for independent evaluations. The plan has been stalled for months at the Capitol because of the Sept. 11 attacks.

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