Most in U.S. Rarely Take HMO Dispute to Higher Level [03/20/2002; Reuters Health] NEW YORK (Reuters Health) - Americans rarely take advantage of state programs for settling disputes with their health plans, even though consumers prevail in 45% of cases, according to a study released Tuesday by the Kaiser Family Foundation. Over a one-year period, consumers filed fewer than 4,000 appeals in the 42 states that now have so-called "external review" programs in place, the study found. Even in New York, with more appeals than any other state, just 10.7 cases were filed for every 100,000 covered individuals. Georgetown University researchers who conducted the study suspect that numerous factors have a hand in squelching consumer participation in external review programs. "There are a lot of barriers at the door of external review," lead author Karen Pollitz, of Georgetown's Institute for Health Care Research and Policy, told Reuters Health. In California, for example, a patient may appeal a health plan's decision to deny a service as not medically necessary if the plan rejects coverage before the patient gets treatment. If the person has already had the treatment, however, individuals are not allowed to retrospectively appeal for coverage of services that they received on their own or that they received without prior approval. There also are "a lot of barriers before you get to that door," Pollitz said. In all but one of the 42 states, for example, individuals must exhaust their health plan's internal appeals processes before turning to the state for help. "I think the big picture policy implication is that we have gotten to a healthcare system that is so complicated that people don't know what to do," she continued. "What we found was that external review, when it works, seems to be a pretty good thing. But if you're the least bit cynical, you begin to wonder why we're making this so hard." Remember we are NOT Doctors and have NO medical training. This site is like an Encylopedia - there are many pages, many links on many topics. Support our work with any size DONATION - see left side of any page - for how to donate. You can help raise awareness of CAM.