As Congress fights over a patients’ bill of rights, citizens of Minnesota had the opportunity to see up-close the impact of a health maintenance organization that looks out only for the bottom line. The settlement between state Attorney General Mike Hatch and Blue Cross and Blue Shield of Minnesota is a major step toward putting some restraints onto large HMOs that do not necessarily work in the best interests of their patients. The lawsuit and settlement brought to the public’s attention that Blue Cross Blue Shield had been denying coverage, to various degrees, for treatment of mental health, eating disorders and chemical dependency for children and young adults. It is fortunate for the state that Hatch was able to have a hand in putting an end to such appalling activities.

Many denials for these types of coverage were made even though insurance premiums had been paid for these services. Many of the denied claims also went against the advice of physicians who deemed treatments medically necessary. This is unfortunate, since it is clear that doctors, not an HMO, are the best determiners of what sort of treatments need to occur. In instances when Blue Cross Blue Shield actually accepted these claims at all, it would sometimes start a patient on a long-term treatment plan, only to then cancel coverage and leave the patient holding the bill. Though this may have saved Blue Cross Blue Shield money, the cost it could have had in the lives of families who were desperate for treatment, yet unable to pay for the care of loved ones, would be high.

Even worse, Blue Cross Blue Shield would sometimes deny coverage for children and then suggest to parents that the children be placed into the juvenile justice system or foster care, so that the treatment they received would be courtesy of government agencies, paid for with tax dollars. The idea that an HMO would suggest that parents place a child in the care of the government, just so they could receive treatment the parents had already paid for, is horrifying. If followed, this type of suggestion is a detriment to both the child seeking treatment and the parents who have to contemplate the idea of letting their child go in order to help them.

The underhanded way Blue Cross Blue Shield operates is truly alarming for any consumer. Saving money is not enough of a reason to deny care for patients. This lawsuit involving Blue Cross Blue Shield points to the larger problem in this country surrounding HMOs, which are not living up to the service their customers pay them and expect to receive. Fortunately, by exposing these disgusting practices, the
settlement also insures that changes will be made. To begin with, Blue Cross Blue Shield has agreed to reimburse the state $8.2 million for treatment the company had denied its paying patients. Additionally, the HMO has agreed to comply with a variety of new procedures, the most important of all being the Review Committee, to be implemented in no later than three months time.

This Review Committee should be a balanced forum for decision making. It will consist of three members. One will be appointed by Hatch, another is to be appointed by Hennepin County Chief Judge Kevin Burke, and Blue Cross Blue Shield will appoint the final member. Under the new rules, Blue Cross Blue Shield is required to process urgent claims within 24 hours and non-urgent ones within two business days of being received. If a claim is denied or the deadlines are not met, the claim then has 24 hours to be reviewed by the Review Committee. That committee then has one business day to reach a decision, which Blue Cross Blue Shield will be legally bound to follow.

Under the agreement, the attorney general’s office has the option of sending an auditor every six months to check on Blue Cross Blue Shield’s records regarding benefits it is handing out. This will allow stricter state oversight to make sure the company is not up to any more mischief. Another condition the settlement requires is that Blue Cross Blue Shield has 60 days to review any outstanding complaint claims submitted to Hatch’s office from the HMOs customers. If the patient’s claims are not resolved, there is the option of outside mediation. This allows the patient a larger share of control of their health care, and the possibility for an outside mediator to fairly judge the claims made.

This is a great step forward for Minnesota patients and it is hoped that other HMOs will follow in the path of Blue Cross Blue Shield. In an agreement like this, it is the patients who come ahead. However, by settling, it appears that Blue Cross Blue Shield can at least admit its mistakes and seems to be willing to take steps to rectify its otherwise deplorable behavior. With more oversight from the government, perhaps this HMO will work to take better care of the people who have, to no small degree, entrusted their care into this monolithic organization. If other HMOs followed in the footsteps of this agreement, it would show that their commitment – as it should be – is with patients, not just profits.