Reform group rips Sierra’s coverage review plan

Art Nadler

Monday, Feb. 8, 1999 | 10:45 a.m.

A decision by the largest health maintenance organization in the state to accept independent reviews of patients' medical disputes has received a cool reception from a leading grass-roots health-care reform organization.

Sierra Health Services Inc. announced Thursday that it would pay for external, independent reviews of coverage decisions under its Health Plan of Nevada division. The criteria would be that the disputed procedure must cost at least $1,000 and be deemed a "medical necessity" or an "experimental treatment."

"We just felt this is a good thing to do," said Ria Marie Carlson, vice president of public relations for Sierra Health. "There are a lot of anti-HMO things out there that gives a misconception of HMOs. This would be a certified, independent review organization that we would contract with and pay for."

The HMO paying for the external review is what concerns Ruth Mills, president of the Nevada Health Care Reform Project. She questions how independent the panel will be if it is paid by Sierra Health.

"It seems strange to me that they are setting up another bureaucracy to do the same thing that their internal review committees do," Mills said. "For a business to set up another business to monitor itself -- maybe they should look at how they are doing reviews now."

The Reform Project is backing an ombudsman bill currently before the Legislature. It seeks to help consumers obtain health insurance by providing referrals and assistance, explain consumers' rights and responsibilities, identify and help consumers solve their complaints and explain state, local and federal laws and regulations.

HMOs, for the most part, have been opposed to the bill creating an ombudsman's office in the attorney general's office. They argue that it would be another bureaucratic agency. Carlson says an independent panel of doctors and medical professionals would be more qualified to review patients' complaints than a state agency.

Sierra Health's independent, external medical reviews will start June 1. Similar services will also be offered in its Texas Health Choice division.