Congress is considering ways to tighten controls on HMOs, and one of the most contentious proposals is to guarantee patients the ability to appeal an HMO's decision to an independent authority. Unlike Al-Warith, people with private insurance generally lack that option. The federal government is working to provide external appeals for people in Medicare and Medicaid, the government insurance programs for the elderly, poor and disabled, and 18 states have required insurers to provide external appeals that vary in their scope and degree of independence. President Clinton has proposed establishing an independent appeals process for all consumers, as a patient's basic right. Some elements of the health insurance industry have resisted legislative mandates, and others say health plans generally do a good job of handling consumer grievances.
Patient advocates see it differently.
Kaiser officials said they recognized the frustration Al-Warith and his wife felt but disagreed with the complaint that Kaiser was unresponsive. The internal appeals that health plans offer consumers often reward perseverance. The panel decided unanimously in her favor. Few consumers take the formal appeals route. CareFirst and FreeState Health Plan, an affiliated Blue Cross and Blue Shield HMO, processed more than half a million medical claims last year and received only 703 grievances, said Antoinette Hopkins, director of member services for the two HMOs.