Elizabeth Dears, Esq.                                                                                                Division of Governmental Affairs

Senior Vice President /                                                                                    MEMORANDUM  IN  SUPPORT

Chief Legislative Counsel


IN SENATE INSURANCE COMMITTEE                                 S.4783-A (DEFRANCISCO)


                                                                                 AN ACT to amend the public health law, in relation to the definition of a clinical peer reviewer

This bill would amend the Public Health Law and Insurance Law to set forth necessary qualifications for a person with whom a health plan must consult before deciding to deny a treatment or needed prescription medication for a patient that has been requested by the patient’s treating physician. The Medical Society strongly supports this bill.

This bill seeks to assure that those who make “medical necessity” determinations on behalf of a health insurance company are appropriately qualified to make such decisions.  Under current law, the only qualification required for a person who, on behalf of a health plan, may contradict the treatment recommendation of the patient’s treating physician is that such reviewer be a licensed physician.   The physician does not even need to be licensed to practice in New York State.   Moreover, there is no requirement that such reviewing physician have the same qualifications as a physician who would typically render or facilitate the treatment that is being recommended for the patient.  Therefore, the person reviewing the treatment request may not have the sufficient training or experience necessary to decide whether the treatment or prescription medication that has been recommended is appropriate.  As a result, care that may be needed for the patient may be unnecessarily delayed or denied while the patient has to resort to taking an External Appeal to attempt to receive the care that has been recommended, which risks putting the patient’s health in jeopardy. 

This bill would ensure that no physician who reviews treatment requests for health plans may deny such request unless such physician is adequately qualified to review the treatment requested, by requiring that such reviewing physician be board-certified or board eligible in the same or similar specialty as the physician who typically recommends the treatment or manage the condition that is under review.  It would also require that such physician have a New York license to practice medicine.  As many more New Yorkers become newly insured as a result of the federal health care reform law, the provisions of this bill would provide needed additional protections to assure that these patients will have coverage for the care they are expecting to receive.

For all the reasons stated above, the Medical Society strongly supports this bill and urges its enactment.

                                                                                 Respectfully submitted,


MMA – support                                                         ELIZABETH DEARS KENT, ESQ.