Author: Richard H. Adler

The "Patient Bill of Rights" for Washington residents (SB6199) overwhelmingly passed the legislature with only a few dissenting votes. It was signed into Washington State law by Governor Gary Locke on March 15, 2000.

This law was a victory for consumers across Washington State and provides patients with many consumer-oriented protections including privacy and insurer accountability. Some of the key provisions also provide indirect benefits to treating health care providers. Key provisions of this law include:

1. Full disclosure of information on coverage.
Insurance companies must provide explicit information outlining exactly what is and is not covered under their health insurance plans, including what prescription drugs are covered. Insurers must disclose when prior authorization for treatment by health care providers is needed and how to get it.

2. Access to health care.
Insurance companies must provide timely referrals to medical specialists; direct access to chiropractic care; and access to a second opinion from the doctor of the patient's choice.

3. Grievance process.
Health insurers must adopt a grievance process for their insureds to use in contesting the denial of benefits with a clear explanation of the steps required during that process.

4. Appeal process and timely independent review.
The insurance company must give written notice and explanation of any decisions adversely affecting coverage or treatment. The patient has the right to ask the insurer to reconsider its decision. The patient can ask for a second opinion as part of the appeal process. If the appeal is denied, the patient can request an independent review by a state certified organization. Insurers have three business days to provide medical records to the review board, and members of that board are empowered to override the insurer's decision. Independent reviews must occur within eight days of a request to for one, and in cases of serious health risks, review must occur within 72 hours. Members of the review board cannot have any connections to the insurance industry.

5. Seek legal action if necessary.
Patients may sue a health insurer for wrongfully denying or delaying access to health services after completing the independent review process. Employers providing health benefits cannot be held liable for health-care decisions made by insurers. Patients have three years from the completion of the review to sue their health insurer.

Patient and provider have a common interest in assuring full and unrestrained access to needed care for treatment of illness or injury, and preventative care. The Patient Rights Bill provides a variety of protections against unfair and arbitrary conduct by health insurers. It's effectiveness will depend, in the first instance, on widespread awareness and knowledge of the public and health care providers. Implementation of this new law will also depend on regulations and rules presently being developed by the Insurance Commissioner's office.

The personal injury recovery attorneys at Adler Giersch PS are available to assist you and your patients when issues arise with respect to changes in the law and all aspects of insurance and personal injury law through our offices in Seattle, Bellevue, Everett, and Kent.

PATIENT BILL OF RIGHTS
The Washington legislature has created new laws to help ensure your right to fair treatment by your health care plan. Some key points are listed below. Contact your health care plan for more information.

Your health plan must tell you:

• What benefits are covered, limited, or excluded. (And why)


• What prescription drug benefits are covered.


• Which doctors (both primary care and specialty providers) and other health care providers are available under the plan.


• When you need prior authorization, and how to get it.


• What is required to see a provider other than your primary care provider.

Referral to Specialists:
Your right to be referred by your primary care provider, when warranted, is guaranteed.

Open Discussion:
Your doctor can not be restricted from informing you of needed care and treatment options.

Second Opinion:
You have the right to a second opinion regarding diagnosis or treatment plan.

Right to Appeal:

• The plan must give you written notice and explanation of any discussion adversely affecting coverage or treatment.


• You may request that the plan reconsider its decision.


• You can request a second opinion as part of the appeal process.


• The plan must consider information submitted and make a decision within 30 days.


• If your appeal is denied, you may request review by a state certified independent review organization, at no cost to you. The determination of the reviewer is binding.

Grievances:
Any complaint about customer service or the quality or availability of care must be processed according to standards approved by the Insurance Commissioner.

• A request for reconsideration of the plan's resolution of a complaint must be processed as an appeal.