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New York Investigates Several HMOs For Possible Violation of a State Law

By Nancy Ann Jeffrey
Wall Street Journal. (Eastern edition). New York, N.Y.: May 13, 1999.  pg. 1
Copyright Dow Jones & Company Inc May 13, 1999

The New York state attorney general's office is investigating some managed-care plans for possibly violating a state law by telling patients and doctors that patients must first get approval from their primarycare doctor to be covered for an emergency-room visit.

The HMOs, which include Oxford Health Plans Inc., Cigna Corp.'s Cigna HealthCare unit and Kaiser Permanente's Northeast health plan, have received subpoenas, the attorney general's office said. The office is seeking materials that it believes would show violations of the socalled "prudent layperson" standard of a 1996 state patient's rights law.

That standard requires health plans to provide coverage of emergency-room visits for people who have symptoms that a prudent layperson would consider an emergency. Under that provision, patients don't have to contact their primary-care doctor first.

Oxford, Cigna and Kaiser said they are cooperating with the investigation. Oxford and Cigna said they believe they are in compliance with the law. A Kaiser spokesman said some materials it had sent to doctors were incorrect and that it is fixing them.

"If you've got a bone sticking out of your leg, you don't have to call your doctor at home to find out if you need to go to the emergency room," said Marc Violette, a spokesman for the attorney general's office.

About 26 states have prudent layperson requirements for coverage of emergency care, and similar legislation is pending at the national level. But some doctors say many patients in managed-care plans still believe they need to get preapprovalsomething they fear will lead to life-threatening delays in coming to the emergency room when treatment is needed.

Ian W. Cummings, medical director of the emergency department at Day Kimball Hospital in Putnam, Conn., says he has seen heart attack patients who have delayed coming to the emergency room because they believed they needed to call their primary-care doctor first.

The attorney general's office said it also has sent subpoenas to a Blue Cross & Blue Shield plan in Utica, N.Y., North AmeriCare in Amherst, N.Y., and HIP Health Plan of New York. HIP has been working with the attorney general's office and now is in compliance with the law, the attorney general's office said. Officials at the three health plans weren't available for comment.

Credit: Staff Reporter of The Wall Street Journal


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