Before the Joint Committee on Health Care
Financing
October 3, 2011
The Massachusetts Medical Society wishes to be recorded in
support of House Bill 1227, "An Act to Further Define Adverse
Determinations by Insurers," legislation that would require that
health insurers defer to the medical judgment of the treating
clinician unless the "preponderance of evidence" showed that the
clinician's requested service "did not meet the requirements for
coverage based on medical necessity, appropriateness of health care
setting and level of care, or effectiveness."
The MMS applauded the Legislature's establishment of the strong
patient protections accomplished by the passage of Chapter 141 of
the Laws of 2000. That legislation has built a strong
foundation for patient protection and has helped to level the
playing field between health insurers on the one hand, and patients
and their physicians on the other. The measure before you is
an important next step in securing additional patient protections
in the area of utilization review.
The MMS believes that clinicians - not health plans - should be
responsible for the determination of medical necessity and the
nature of care offered. Today, those decisions are made by
insurers during the utilization review process - and often by
non-medical personnel who have had limited, if any, contact with
the patient. The burden is then placed on the patient and the
physician to try to overturn those adverse decisions. This
legislation would change the "burden of proof" and place the
medical decision-making authority where it ought to be - in the
hands of the clinician who is directly treating the patient and who
is closest to the case!
We urge the Committee to report out this bill favorably.
