Hmo Emergency Room Policy Revised

Attorney General Spitzer announced today that, at the direction of his office, Health Insurance Plan of Greater New York, Inc. (HIP) has revoked its onerous and unlawful emergency room policy requiring pre-approval by the company before emergency room physicians could admit HIP members.

"In a medical emergency, people must be able to trust that the doctors from whom they seek treatment are focused exclusively on providing them the care they need," said Spitzer. "While other considerations, such as arrangements to pay for services have their place, they must clearly be secondary to providing timely and effective care."

HIP notified hospitals in the greater New York City area last October about its new emergency room admissions policy. Under the policy, emergency room doctors were required to contact the HIP member’s primary care physician who would then call HIP requesting pre-approval for emergency room services. Personnel at HIP would then call the hospital to approve or deny emergency room treatment for the patient.

HIP’s pre-authorization policy threatened patients’ safety by imposing procedures that could delay time-sensitive care. The policy also put hospitals under pressure by threatening that if they didn’t comply with the process they would not be paid by HIP for emergency room services rendered to HIP members.

HIP’s policy violated state laws that bar pre-authorization for emergency room services and ban requirements that health maintenance organizations (HMOs) be informed or contacted before emergency treatment is provided. It also violated the "prudent layperson" standard of New York law which prohibits HMOs from denying payment for members who go to the emergency room in the reasonable belief that their condition is an emergency, even if that belief later turns out to be mistaken.

Spitzer issued a subpoena for documents from HIP on March 1. Late last week the Attorney General’s office approved a re-written HIP policy on emergency room treatment that will be sent to all affected hospitals this week.

Spitzer’s involvement in the case was cheered by an association representing 175 hospitals and long-term care facilities in the greater New York City area:

"These actions will decisively help ensure that New Yorkers receive appropriate emergency treatment, and that hospitals delivering such services will not be burdened by illegal and inappropriate payer practices," said Kenneth Raske, president of Greater New York Hospital Association.

"HIP’s policy rode roughshod over considerations of patient safety and compliance with the law," said Troy Oechsner, an Assistant Attorney General working on the case. "On its face their policy plainly violated both the letter and spirit of state law."

Lawyers in the Attorney General’s office will review HIP documents to determine whether any of its members were harmed or denied emergency room services under the company’s policy.

HIP’s 800,000 members live in New York City, Long Island and Westchester, Rockland and Orange counties.