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Court: States Can Help Fight HMOs

June 20, 2002

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WASHINGTON (AP) _ A heavily divided Supreme Court ruled Thursday that states can help patients fight their HMOs, a decision that could increase requests for second opinions.

The court voted 5-4 to endorse an effort, like those used in about 40 states, to let patients bypass health plan gatekeepers who refuse to approve payment for a treatment. The ruling also lifts pressure off Congress, which has failed to pass a national patients’ rights plan.

The state laws are 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 Supreme Court said that states, in trying to better arm patients in their battles with big HMOs, did not conflict with a federal law.

The ruling comes months after patients rights legislation stalled at the Capitol after the Sept. 11 attacks, putting on hold plans for a nationwide system for independent evaluations. The subject has been part of closed door talks this year, with no consensus.

HMOs had argued that they were not opposed to independent review boards, but wanted one national standard instead of the hodgepodge of state laws.

The Supreme Court upheld the Illinois procedure used by Debra Moran to get her health plan to pay for an operation that fixed her rare, debilitating nerve problem. The surgery cost about $95,000.

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