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HMO Regulation in the Future

October 04, 1996
hmo3.djf Length:

By: David Freitas

Regulation of HMO's is becoming an important issue both in the federal government and here in Missouri.

Missouri experienced a 50 percent increase in HMO membership last year alone.

And that's prompted local legislators to take a closer look at managed care.

Ciprian Boltoi reports on how Missouri officials are looking at managed care regulation more carefully.

OutCue: SOC

With disputes over HMO care growing increasingly common, states and the federal government are looking for answers.

Last year the Missouri legislature introduced several pieces of legislation in an attempt to reform HMO's.

None made it to the governor's desk.

But an interim legislative committee has been studying managed care.

Mexico Senator Joe Maxwell says the committee is very concerned about HMO's and regulation.

RunTime: 22
Contents: Maxwell says the committee needs to consider independent regulation.

Right now the Missouri Department of Insurance does have some powers to regulate HMO's.

It handles certain appeals processes... mostly complaints that involve issues of payment.

For the past year the department has had a panel of doctors review 18 cases involving medical necessity.

The problem with medical necessity comes up when a patient disagrees with what the HMO determines is or is not medically necessary.

So far 8 of the cases have been settled in favor of the patient.

But the power of the Department of Insurance is limited to mostly financial matters, and issues of customer concerns are often not dealt with at the state level right now.

And while it can set up certain regulations... Randy McConnell, a Department of Insurance spokesman, says he hopes legislators will address the issue.

RunTime: 14
Contents: McConnell says the state needs to provide the regulation in order to avoid legal challenges.

Even Dr. Joe Huguenard, the Corporate Medical Director of Alliance Blue Cross-Blue Shield, says HMO's need a government eye watching over them.

RunTime: 28
Contents: Hugenard says that regulations should exist so people have a sense of standards.

The legislative committee is expected to report its findings in early November.

That report will offer suggestions to legislators planning to make managed care a part of their agenda during the next legislative session.

For KBIA's Capital Edition, I'm Ciprian Baltoiu.

Additional Sites of Interest

Read other MDN stories on the 1996 legislative action on HMO's:

  1. Senate Split Over Managed Care (May 1995)
  2. HMO Regulation Stalls in Committee
  3. Leadership Stalls HMO Regulation
  4. Regulation Provisions
  5. Complaints Prompt Legislative Action