Copyright 1999 Federal Document Clearing House, Inc.
Federal Document Clearing House Congressional Testimony
May 06, 1999
SECTION: CAPITOL HILL HEARING TESTIMONY
LENGTH: 955 words
HEADLINE:
TESTIMONY May 06, 1999 JOHN A. BOEHNER REPRESENTATIVE HOUSE
EDUCATION AND THE WORKFORCE EMPLOYER-EMPLOYEE RELATIONS EXTERNAL REVIEWS OF
HEALTH PLAN DECISIONS
BODY:
STATEMENT OF THE
HONORABLE JOHN A. BOEHNER CHAIRMAN SUBCOMIM ITTEE ON EMIPLOYER-EMEPLOYEE
RELATIONS May 6, 1999 Hearing On: "THE IM1PACT OF EXTERNAL REVUE ON 11 EALTH
CARE QUALITY Good morning everyone and welcome to our fourth hearing in a series
examining the different aspects of employer-sponsored health
plans. Today we will hear from a panel of witnesses who will discuss the impact
of an external review mechanism on health plans. At our last
hearing, the subcommittee heard from witnesses about the participant protections
currently available in ERISA. Today's hearing is a natural follow-up. This
hearing will focus on whether additional protections are needed and any
suggestions as to how to implement them. We want to look at whether ERISA should
be amended to provide a mechanism to resolve disputed benefit claims through an
independent third-party. Let me just say that at the last hearing we learned
that ERISA contains strong, enforceable protections for benefit dispute
resolution. The Act also contains strong remedies against fiduciaries that
breach their duties. But we also heard that there may be a need to ensure a fair
process to address disputes that are not resolved under the present ERISA
structure. In most instances, independent third-parties are best to resolve the
more complicated disputes. The best method for arbitrating benefit disputes is
for independent third-parties to make an unbiased opinion and recommendation.
Creating a procedure where disputes could end up in court for years, possibly
depleting plan assets, would do more harm than good and is not the answer. I
hope we all agree that what ever we do must not result in a process where cases
languish in the process. I would welcome any comments the witnesses have on this
subject. If we are to create an external review mechanism, we must design a
process that withstands the test of time. ERISA has worked well for 25 years.
Any major modifications, must be done for the right policy reason, and not for
political expediency. External review should guarantee a fair and expeditious
process, not a specific outcome. 16 previous congressional testimony it was
stated that "Congress cannot guarantee an optimal patient outcome. Participants
should have a right to a fair process for reviewing decisions and to a
well-informed decision. It may be reasonable to punish parties that deny a
participant a fair process. It is not reasonable to punish parties that provide
a fair process because that process does not yield a particular result." I think
that captures the essence of the issue. We must ensure that patients have due
process in the case of legitimate disputes, but not a particular result. I am of
the impression that most of the reason we are talking about these issues is
because some think that external review is going to guarantee that some things
not now covered would be reversed if subject to external review. We want to be
carefull not to favor any party in the process. Employers shouldn't be
guaranteed that improper decisions should stand and patients should not be
guaranteed that things not now covered would be covered after external review.
Remember the guiding theme: a fair and expeditious process, not a particular
result. Furthermore, at our last hearing witnesses testified that plans deny
approximately 3% of all claims submitted to the plan. Of this 3% denial, at
least one quarter are reversed on internal appeal, leaving a small percentage of
the overall claims for care not paid for by the plan. Additionally, we learned
that there are many instances where the individual care -that a participant
ultimately receives after a review process has been completed is enhanced by the
interaction between health professionals. Even though
statistics show that the vast majority of participant claims are paid by
health plans, we would like to explore the possibility of
requiring employer- plans to offer an external review mechanism to possibly
enhance the existing quality of care. Last week, the Employee Benefit Research
Institute (EBRI) released the results of their survey which showed that
participants with employer sponsored health coverage are
clearly satisfied with this system and are not at all interested in switching to
an individual based health coverage system. The EBRI president
stated that " Strong support for the employment-based system is the result of
respondents' satisfaction with their health protection, and
their high confidence that their employers and unions make the best selection
available." We would like to build upon this employee confidence to make the
employer sponsored health plan an even better system of
health care coverage and to expand this viable means of
providing health coverage to as many uninsured
Americans as possible. During our hearing today, we hope the witnesses will
address certain specific issues concerning the establishment of an external
review process on employer-sponsored plans. Such items should include a
threshold for review, the selection of a reviewer, the scope of review, whether
the decision should be binding on the plan and any other facets of the procedure
that they feel should be considered. These specific points should be placed in
the context of our over- all goal of providing patient protections without
significantly increasing the cost of health coverage. I would
hope that during the hearing, the witnesses' would provide their view on whether
or not an independent external review is preferable to civil liability in the
court system. Along the same lines, would a mandatory external review process
enhance consumer confidence in health plans? I look forward to
hearing from our panel of witnesses.
LOAD-DATE: May 6,
1999 
