TITLE

Independent External Review of Health Maintenance Organizations' Medical-Necessity Decisions

AUTHOR(S)
Mariner, Wendy K.
PUB. DATE
December 2002
SOURCE
New England Journal of Medicine;12/26/2002, Vol. 347 Issue 26, p2178
SOURCE TYPE
Academic Journal
DOC. TYPE
Article
ABSTRACT
The article discusses the decision administered by the U.S. Supreme Court in the case Rush Prudential HMO, Inc. v. Moran with reference to the federal Employee Retirement Income Security Act (ERISA) of 1974. On June 20, 2002, the court in this case upheld an Illinois state law which necessitates binding independent external review when a health maintenance organization (HMO) disagrees with the decision of a patient's physician that a treatment is medically necessary. The Court's decision turned on a technical analysis of ERISA preemption. The decision is reported to be opening the door to more extensive state regulation of HMOs. The court has now made clear that state independent-review laws can be applied to HMOs which sell their own policies to fully insured ERISA plans.
ACCESSION #
24943000

 

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