NEW YORKERS USING EXTERNAL REVIEW LAW ARE WINNING ACCESS TO NECESSARY CARE

Superintendent of Insurance Gregory V. Serio and State Health Commissioner Antonia C. Novello announced that thousands of New York State consumers are exercising their health insurance rights and are winning access to necessary care under the State's External Review Law, according to the latest External Review Report released today. "New Yorkers have been empowered by the External Review Law and are availing themselves of this important appeal mechanism when their essential health coverage is denied by the insurer," Serio said. "Since this Law became effective on July 1, 1999, more than 5,000 consumers have requested external appeals. With an average of 46% of external review cases overturned, this means that over 2,000 New Yorkers have access to health insurance care that would not otherwise have been made available to them. This year’s External Review Report illustrates that under Governor Pataki’s leadership consumers are educated on their health insurance rights and using this knowledge to ensure necessary coverage." "Thanks to Governor Pataki, New Yorkers enjoy the most comprehensive patient protections in America," State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H., said. "The success of the external review process demonstrates that patients in our State know their rights and are taking advantage of the opportunity for a prompt, independent and professional appeal when they believe an insurer has made an arbitrary decision. This Law better ensures that medical treatment decisions are made by doctors and their patients, and that New Yorkers receive the quality health care they need and deserve." The External Review Annual Report, released by the State Insurance and Health Departments, provides a comprehensive overview of New York's External Review Program and includes a description of external review results from the past year. The report also provides information about the external review programs of other states and compares the experience of other states to that of New York. Highlights from the report include: The Insurance Department has received 5,000 requests for external appeals, over 1,300 in 2002. Since July 1, 1999, 1,110 denials of coverage by health insurers have been overturned in whole, 267 denials have been overturned in part and an additional 722 denials have been voluntarily reversed by health plans before an external appeal agent rendered a determination. 183 expedited external appeal requests have been assigned to agents for review since July 1, 1999. An appeal must be expedited if the patient's physician attests that a delay in treatment would pose an imminent threat to the patient's health. Agents must render a decision on expedited appeals within three days. In 2002, 44% of medical necessity denials were overturned in whole or in part by external appeal agents while 50% of experimental or investigational treatment appeals were overturned. External appeal requests are submitted to the Insurance Department, which screens requests for eligibility and completeness and assigns the appeal to one of the state's three certified external review agents. The External Appeal Annual Report, applications to request an external appeal, and external appeal information are posted on the Insurance Department’s Web site at www.ins.state.ny.us. The Insurance Department’s external appeal hotline, 1-800-400-8882 assists New Yorkers in filing external appeal requests. The Insurance Department also has staff on-call seven days a week to handle expedited appeals.