Independent appeals get new lease on life in Texas

U.S. Supreme Court asks lower court to reconsider its ruling against the law permitting reviews of health plan coverage denials.

By Tanya Albert, AMNews staff. Nov. 4, 2002.

Physicians have asked a federal appeals court to uphold a Texas law allowing patients to appeal health plan decisions in light of a U.S. Supreme Court ruling this summer favoring such state laws.

The 5th U.S. Circuit Court of Appeals in 2000 ruled that the federal Employee Retirement Income Security Act of 1974 preempted the Texas law, which established an independent review process for patients who dispute health plan decisions to deny coverage of a medical procedure recommended by a physician.

A few days after issuing its ruling, the Supreme Court vacated the 5th Circuit's decision and sent it back to the lower court for reconsideration. In their recently filed briefs in support of the Texas law, the state of Texas and physicians said that independent review best serves patients' interests.

"The independent review panel significantly strengthens the patient-physician relationship," said Leonard Nelson, director of the AMA/State Medical Societies Litigation Center. The center filed a friend-of-the-court brief on behalf of the AMA and the Texas Medical Assn. in the Corporate Health Insurance v. Texas Dept. of Insurance case.

"The independent reviewer, not having a personal financial or professional stake in the outcome, can be the most objective party to make a decision concerning medical necessity," added Jose Montemayor, Texas Dept. of Insurance Commissioner. "It is a critical feature of our patient protection legislation."

Health plans have not opposed independent review laws. When the companies originally challenged the 1997 Texas Health Care Liability Act, they did not object to its independent review provisions. [...]