Only seven of those states have also passed statutes expanding health plan liability. While most states have enacted external review, they continue to revisit the issue, modifying their requirements as they study patients' experience with the system. These programs allow patients to challenge coverage denials if they are made on the basis that treatment is medically unnecessary or experimental. The California Association of Health Plans also announced that all of the state's largest health plans would voluntarily implement similar programs. NCQA held off putting its standards in place to avoid duplication and confusion, given all of the state laws and pending federal legislation.
Many plans have at least one year of experience managing external review programs.
That balance is an indication that reviews are indeed independent and that despite the difficult issues being considered, reviews have not been biased. AAHP's survey also showed that, based on the number of cases accepted for review, annual appeal rates typically were under 1 per 10,000 members. Taking the Initiative Virtually every state law mandates that patients be informed of their right to appeal plan decisions, and plans are working to make sure that patients understand their rights. At first glance, the number of cases going to external review appears small. For example, at Empire Blue Cross and Blue Shield, the largest health insurer in New York, its 4.1 million members filed 27 external appeals during the second half of 1999 when a new appeals law took effect.