Before the Joint Committee on Financial Services
The Massachusetts Medical Society wishes to be recorded in support of Senate Bill 453 and House Bill 936 “An Act to Further Define Adverse Determinations by Insurers.” These identical bills 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. Those provisions have been further strengthened over the years, most recently by Chapter 224 of the Acts of 2012, the payment reform law. 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 support Senate Bill 453 and House Bill 936 and to report this legislation out of committee favorably.
