OPINIONHMO review: Supreme Court will decide who gets final sayThe U.S. Supreme Court will soon hear a case that would empower patients in many states to get the independent reviews that would let them challenge HMO treatment decisions.Editorial. Jan. 14, 2002. One of the U.S. Supreme Court's first acts of 2002 will be to take up the matter of Rush Prudential HMO Inc. v. Debra C. Moran and the State of Illinois. The case is expected to determine the future of state laws requiring independent review of health maintenance organization decisions to deny coverage for patient care. Such mandates are among the key elements in ensuring patient rights in the era of managed care. Nearly 40 states have enacted such sensible laws, which provide patients with protection from HMOs' vested interest to avoid spending money. What stands in the way of those laws is the federal Employee Retirement Income Security Act of 1974. Complex and arbitrary, ERISA is the managed care industry's cherished trump card. Health plans argue, and courts have traditionally agreed, that ERISA shields employee benefit plans from state-level accountability, such as lawsuits over treatment decisions and independent review laws. The U.S. 7th Circuit Court of Appeals made the latest ruling on the Moran case and it upheld the Illinois state law mandating a patient's right for an independent review of an HMO decision. In this instance, Debra Moran spent nearly $95,000 of her own money for shoulder surgery -- suggested by both the surgeon and her primary care physician -- that her HMO had refused to cover. Even after a court ordered an independent review that found the surgery was medically necessary (although the reviewer would have preferred another procedure), the plan still wouldn't pay.
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