This legislation would amend the definition of adverse determinations to require that decisions by insurance carriers “defer to the judgment of the treating clinician[,]” unless there is a preponderance of evidence that the requested service does not meet the qualifications of medical necessity. This added burden of proof would ensure that medical decisions are made by attending clinicians, who are familiar with the patient’s condition and need for treatment, and not the insurance carrier. This would not take away the insurance carrier’s ability to conduct a utilization review of the service. The utilization review organization or the insurance carrier would still be able to deny coverage of a service; however, they must show through substantial evidence that the service is not medically necessary. (This bill is a refile of H. 1079 from the 2009-2010 Legislative Session. It currently sits in the Joint Committee on Health Care Financing.) |
