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?”

Medical Malpractice Cases: The Pros & Cons of a Cap on Non-Economic Damages

By Alicia M. Dodge, Albany Government Law Review Class of 2011

Introduction:                        

Is a $250,000.00 cap on non-economic damages in medical malpractice cases necessary?  The answer to this question will vary widely, depending whom you ask.  The New York State Bar Association and patient-rights advocacy groups strongly oppose this cap, while hospitals and physicians generally support it.[1]  The purpose of an economic damages award, such as loss of earnings, is to make an injured person “whole” again, and can generally be calculated with a fair amount of certainty.  On the other hand, an award of non-economic damages, such as pain and suffering or loss of consortium, “cannot be precisely measured in money,” and as such are often viewed as arbitrary rewards.[2]   Continue reading “Medical Malpractice Cases: The Pros & Cons of a Cap on Non-Economic Damages”

HEAT Summit Seeks to Help Cure a Dying System: The Obama Administration and the Battle Against Health Care Fraud

 Lynn Nolan, Government Law Review member

             Approximately $125–175 billion are lost to fraud each year in both the private and public health care sectors.[1]  The FBI estimates that in fiscal year 2009, $75–250 billion were stolen from public and private healthcare programs through fraudulent billings alone.[2]  With the prevalence of health care fraud becoming more apparent the government is taking action to prevent and prosecute fraudulent activity.  President Obama has made combating health care fraud a priority of his administration by encouraging the development of innovative methods of preventing fraud and pursuing policy changes to facilitate reform.[3] 

            One of the Administration’s signature initiatives is the Health Care Fraud Prevention and Enforcement Action Team (HEAT), which is a collaborative task force derived from the Department of Health and Human Services (HHS) and the Department of Justice (DOJ).[4]  The HEAT task force was established on May 20, 2009 to aid in the identification of perpetrators of fraud in order to recover funds which have been stolen and prohibit perpetrators from abusing federally funded health care programs, such as Medicare and Medicaid.[5]  The latest initiative of HEAT was the National Summit on Health Care Fraud which was held on January 28, 2010.[6]  The National Summit was held to address the issue of health care fraud and promote the participation of the private health care sector in collaboratively fighting fraud to aid government efforts.[7]  Secretary Sebelius addressed the private sector in saying,

[h]ealth care fraud isn’t just a government problem.  Criminals don’t discriminate and they are stealing from Medicare, Medicaid and private companies at an unacceptable rate . . . [w]e have a shared interest in stopping these crimes and today’s summit brought us together to discuss how we can all work together to fight fraud.[8] 

Continue reading “HEAT Summit Seeks to Help Cure a Dying System: The Obama Administration and the Battle Against Health Care Fraud”