Will The Patients' Bill Arrive Alive?

Dem

ocrats made sure the MCCAIN-EDWARDS-KENNEDY bill reached the Senate floor first. But many Republicans hope to modify it with large chunks of the rival BREAUX-FRIST-JEFFORDS bill (or kill it outright with amendments). Kennedy will have to budge on some issues--like whether the bill will pre-empt state laws. Bush hopes the bill gets weakened before it reaches the conference committee, leaving room for compromises he wants.

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APPEALS PROCESS Patients can ask the insurer for a timely internal review of a decision, and then appeal for an external, independent review by doctors. If there is a chance of irreparable harm while the review is pending, the patient can skip appeals and go straight to court.

RIGHT TO SUE After appeals are exhausted--whether or not the review has found in favor of the patient--patients or families can sue for damages in state court over medically reviewable decisions. Or they can sue in federal court for administrative decisions that cause irreparable injury or death. (They can't sue in both forums at the same time.)

DAMAGES In state court, patients or families can sue for whatever damages state law allows--in many states, such liabilities are uncapped. In federal cases, they can sue for economic damages and pain and suffering, and up to $5 million in punitive damages if the insurer acted flagrantly and in bad faith.

PHYSICIAN SAFEGUARDS Health plans are prohibited from offering financial incentives to doctors to limit medical services. Insurers are forbidden to punish doctors who advocate on a patient's behalf during the appeals process.

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APPEALS PROCESS Same internal appeal, though a bit slower--but the insurer gets to pick the doctors performing all external reviews. Patients need to exhaust all appeals before filing suit, but they can ask a court to order treatment if they can prove immediate and irreparable harm.

RIGHT TO SUE Patients or families can sue for damages in federal court over medically reviewable decisions, but only if the external review reverses the insurer's decision. No suits allowed in state court--which could pre-empt several state patients'-rights laws.

DAMAGES In federal court, economic and pain-and-suffering damages are capped at $500,000. Patients and families cannot sue for punitive damages.

PHYSICIAN SAFEGUARDS No provision on doctors who support patient appeals. Doesn't ban financial incentives to doctors to limit care but mandates a study of the issue by the Department of Health and Human Services.