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This week from Charleston

By Staff | May 6, 2013

One of the bills awaiting the Governor’s signature is HB 2960, would allow consumers to appeal denials of coverage by health insurance companies. The bill is a very narrow state implementation of a part of the Affordable Care Act, which creates “Independent Review Organizations” or “IROs.” In the future when a consumer is denied a medicine or a procedure by a health insurance company, a consumer will be able to appeal to an IRO. IROs will use the expertise of board-certified doctors nationwide, and use evidence-based medical case review approach to resolve coverage disputes between consumers and their health plans. One example of the need for an IRO is when an insurance company denies a specific medicine that a doctor prescribes. The IRO, made up of a panel of doctors, will decide whether the denial was based on medical evidence. This is a part of the Affordable Care Act, regardless of HB 2960, but the bill would speed implementation and compliance in West Virginia.

This bill allows for the appeal in a West Virginia court of decision made by an IRO. The consumer or the insurance company can launch an appeal of the IRO decision. One reason, I write about this bill is because I was able to make a significant amendment requiring that the venue for the court appeal would be the county where the consumer lives. In the original bill, the venue for an appeal would have been in the county where the consumer lives or in Kanawha County. What this would have meant is that a consumer in Jefferson County could have gotten a favorable ruling from an IRO on a medicine, and then the insurance company could choose to appeal that by filing a lawsuit in Kanawha County!

What I was able to do was to make sure that the appeal could only happen in the county where the consumer lives. Sometimes intentionally and sometimes unintentionally, legislation gets drafted that ignores the fact that Jefferson County, and many other counties, are very far away from Kanawha County. We simply get ignored. That is why it is so important for the Eastern Panhandle to have representation on the major committees. This was a very well intentioned bill-one that gives consumers more rights-but that ignored the fact that insurance companies are likely to file most of their appeals in Kanawha County. Fortunately, my amendment was accepted, and the Senate agreed with the changes. Hopefully the Governor will sign the bill.