| OCR Text |
Show Hinckley Journal of Politics 2006 MCO, that patient will have to pay for their services out-of-pocket. Sometimes, patients in emergency situations can run into problems as well. While MCOs recognize emergency care and will cover the cost of essential emergency care (often this is a legal requirement), patients that require an imminent procedure but can stand to be transferred first, will sometimes be moved to a participating provider to receive treatment. Other times, a patient awaiting treatment can be made to Wait until the participating doctor returns to work, even if another, equally qualified doctor is available. In some cases, the delay or transfer before receiving treatment can incur some further medical problems, and usually carries some additional financial cost. At any rate, it seems illogical and unnecessary that a patient should be made to wait or be moved before treatment if there is another qualified doctor or hospital just standing idly by. Given all of these potential benefits as well as drawbacks, Americans usually find themselves facing a tough choice: lower insurance premiums through an MCO or expanded choice of providers through standard indemnity insurance -commonly known as fee-for-service. This model allows Patients to see whomever they want, leaving the provider responsible for billing the insurance company directly. However, since about 63% of Americans who have insurance receive it through their employer, there is often little choice available to them as to where they get their coverage (Congressional Budget Office, 2003, p.l). Any Willing Provider Solving these pesky problems of patient choice and physician access has been the major stated goal of Any Willing Provider legislation. The first laws of this kind were passed in the early and mid-1980s, but most of them were passed in the 1990s, mostly on the coat-tails of the national debate on healthcare started by the proposed Clinton-era reforms. These laws, in general, require an MCO to either accept into their panel any healthcare provider willing to meet the terms of the contract °r just outright pay for services rendered by out-of-network Providers, regardless of network membership. (The latter is sometimes referred to as Freedom of Choice (FOC) or Mandatory Point-of-Service (MPOS) legislation, but for the Purposes of this paper both types of legislation will be generally referred to as AWP, unless otherwise specified). Therefore, by requiring health plans to cover procedures performed by out-of-network providers, AWP legislation strives to restore patient choice and prevent the mandatory switches in care providers that have long been a point of contention. AWP would also alleviate the problems faced by those rural Patients who sometimes find themselves somewhat isolated from the nearest in-network provider. Any Willing Provider in Utah During the Utah Legislature's 2005 General Session, Senator Chris Buttars sponsored Senate Bill 34 - Patient Access Reform. The bill was proposed several years prior and had failed under the moniker of being only an amendment to the state's reimbursement laws, but Sen. Buttars brought it back anew in 2005 under a fresh slogan: Any Willing Provider (Buttars, 2005) Actually, the bill is merely an amendment to Utah's already existing reimbursement law, or Freedom-of-Choice (FOC) law as it could be known. However, the current Utah law is, for all intents and purposes, useless. Utah Code Section 31A-22-617 stipulates that an insurance provider must pay for the services rendered by an out-of-network provider, but it only requires that "the insurer shall reimburse the insured for at least 75% of the average amount paid by the insurer for comparable services of preferred health care providers who are members of the same class of health care providers" (Utah Code, Sec. 31A-22-617). As a customer of an MCO, then, a patient must follow several steps; first pay for the services of an out-of network provider out-of-pocket, and then request reimbursement from their insurance company. Then, once they get the reimbursement check, the amount is still only 75% of the average cost for that procedure, which is usually substantially lower than their original out-of-pocket costs. Senate Bill 34, had it passed, would have amended that section of the Utah Code to change the reimbursement rate and created another section requiring an MCO to make the payment for services rendered directly to the provider, therefore no longer requiring the patient to seek reimbursement themselves. It would have further stipulated that the MCO pay up to 95% of what they would otherwise pay for the same procedure to one of their in-network providers. Therefore, SB 34 would have a discount built in for MCOs; they could save that 5% on their normal reimbursement rate when patients go to an out-of-network provider. The only catch would be whether the chosen doctor or clinic would be willing to accept that particular reimbursement rate. Supporters of the Utah bill argue this discount would prevent MCOs from having to pay higher prices and, in turn, forcing them to raise their premiums. Legal Challenges Any Willing Provider laws have faced a substantial amount of legal trouble during their tenure, leaving several laws overturned completely and many others caught in tough battles for several years. Many of these challenges have arisen from an alleged conflict with a federal statute known as the Employee Retirement Income Security Act (ERISA). Passed by Congress in 1974, this law was designed to protect consumers and their retirement assets, at that time accumulated primarily in pension plans, from abuse. Providers of such plans must meet several requirements: they must disclose most of their plan's terms and conditions; provide coverage to at least a cer- 77 |
