The external review process is the best means of guaranteeing all patients that they will get the care they need, when they need it. Sixteen states and the Medicare program have mandated external reviews to help settle disputes between HMOs and their members. Legislation requiring an external review process for California health plans failed to pass last legislative session, but the issue is likely to be reconsidered next year, experts predict.
Many consumer advocates believe that legislating external review processes is the better option.
On the one hand, it's a step, but on the other hand, it perpetuates the fragmented system by allowing each plan to set up its own external review system. Consumers need standardized and fair terms of access. The CAHP recognizes that voluntary reviews processes aren't as good as mandatory processes, Zelman said. The association will continue to advocate for external reviews legislation. Another concern for consumers under the program is that external appeals are guaranteed only after internal appeals processes have been exhausted, Imholz said.