External Appeal in New York; Are Recent Changes Enough?

By Hunter Raines, Albany Government Law Review

New York’s external appeal legislation, giving patients and health care providers a right to an external appeal of health plan adverse coverage determinations, has been invaluable in improving the patient’s access to care while protecting the provider’s right to adequate reimbursement for health care services.  However, changes enacted in July 2011 measurably impact the operation of this statutory creature, which merits examination and review of the process as it currently stands.[1]

In the early 1990s, the rising costs of health care inspired a new insurance model closely tied to the concept of strict care management.[2]  By strictly managing consumer options, health care costs were constrained.[3]  However, this model encumbered access to needed health care for many.[4]  New York’s Managed Care Reform Act, signed by Governor Pataki in 1996, provided new protection for New York consumers in the health insurance market.[5]  Since the passage of the act, consumers now have the right to obtain a description of services and procedures covered by their health plan, the right to an explanation of the patient’s financial responsibility for such procedures and services and the right to appeal adverse coverage determinations.[6]  These legislative protections are far reaching, applying to most health plans excluding those which are self-funded or otherwise subject to ERISA, which is beyond the scope of this article.[7] Continue reading “External Appeal in New York; Are Recent Changes Enough?”