FOR IMMEDIATE RELEASE:
June 28, 2000
Final Provisions of Managed Care
Reform Begin July 1
State Medical Society Lauds
Improved Access to Quality Care
Chicago –– Extending the rights of patients, the last two pieces of the Managed Care Reform and Patient Rights Act will take effect in Illinois on July 1, 2000. Much of this crucial relief for managed care patients took effect January 1, but two final elements begin July 1: Patients will have a smoother transition when changing doctors and physicians will have an easier time providing needed care for their patients.
"The Illinois State Medical Society fought hard for this act because it means managed care patients have more rights in obtaining quality health care," said LeRoy Sprang, president. "It took us four years, but it is an important new law that means better, quicker care for patients when they need it."
The first new provision addresses continuity of care. When a contract between a physician and a managed care plan is terminated, patients covered by that plan will have 90 days to find another physician within the plan. Or, when a patient starts a new plan, if the primary care physician is not a contracted provider, the patient will have 90 days in which to find a new physician contracted to provide services for the new plan. In either instance, the physician will have to agree to abide by the terms of the plan, including utilization review. These continuity of care provisions also apply to post-partum care if the patient is in her third trimester of pregnancy.
The second provision addresses utilization review - the process that managed care companies use to decide whether or not they will approve payment for the medical care a doctor recommends. Plans will have to follow the requirements of a nationally recognized accreditation association, the American Accreditation Healthcare Commission, also know as URAC.
Under URAC, any entity performing utilization review must now provide/guarantee:
! Timely decisions.
! Multiple levels of peer review.
! Disclosure of review criteria when physicians receive a denial.
Timely decisions. Utilization review delays will be minimized. Initial utilization review must be done within two business days - one business day for urgent situations, for extending a stay, or for additional services. Most appeals must be reviewed within one business day. There is no prior approval required for emergency care.
Multiple levels of peer review. Only a doctor will be able to say "No" under the new guidelines. A nurse may take information and ask questions, but only a doctor in the appropriate area of expertise will be able to deny a request.
Disclosure of review criteria when physicians receive a denial. When UR results in a denial, physicians will be privy to review criteria that led to that denial. The standards must be based on sound, scientific evidence. If they are based on junk science or questionable evidence, the utilization program will be in violation of Illinois law.
These changes are the last leg of the Managed Care Reform and Patient Rights Act that took effect On January 1, 2000. The law was developed to protect patients by giving them more information, freedom to choose their physician(s), and the right to appeal health plan decisions. The law includes the right to understandable and complete information on managed care plans, the right to freely discuss all treatment options with the physician of the patient’s choice, the right to seek needed emergency care, and the right to external appeal.
The Illinois State Medical Society (ISMS) played a big role in pushing for its passage each year since its initial introduction in 1996. Rep. Frank Mautino (D- Spring Valley) and Sen. Thomas Walsh (R-La Grange Park), sponsored the enacted bill and played important leadership roles in moving this issue forward along with Governor George Ryan, Sen. Rep. Mary Flowers (D-Chicago) Rep. Jeffrey Schoenberg (D-Evanston) and Rep. Carolyn Krause (R- Mount Prospect).
The Illinois State Medical Society is a professional organization that represents and unifies its physician members as they practice the science and art of medicine. The Society represents the interests of member physicians, advocates for patients and promotes the doctor/patient relationship, the ethical practice of medicine, and the betterment of the public health.
ISMS permits and encourages reproduction of ISMS news releases with the request that ISMS is credited as the source of the information.