[Congressional Record (Bound Edition), Volume 147 (2001), Part 2]
[House]
[Pages 1848-1851]
[From the U.S. Government Publishing Office, www.gpo.gov]



        IN SUPPORT OF BIPARTISAN PATIENT PROTECTION ACT OF 2001

  The SPEAKER pro tempore (Mr. Simpson). Under a previous order of the 
House, the gentleman from Texas (Mr. Green) is recognized for 5 
minutes.
  Mr. GREEN of Texas. Mr. Speaker, I rise today as an original 
cosponsor of the Bipartisan Patient Protection Act, which was 
introduced last week by the gentleman from Michigan (Mr. Dingell), the 
gentleman from Iowa (Mr. Ganske), Senator John McCain, and Senator Ted 
Kennedy. I am proud to be part of the bipartisan coalition that 
hopefully will finally enact a strong Patients' Bill of Rights.
  Mr. Speaker, Americans have been clamoring for a Managed Care Reform 
for a number of years. They want Congress to enact legislation that 
puts medical decision-making back in the hands of doctors and patients. 
They want legislation that provides meaningful accountability. In 
short, they want the Dingell-Ganske Bipartisan Patient Protection Act 
of 2001.
  This legislation provides patient protections that are very similar 
to those that have been the law in my home State of Texas since 1997.
  A recent article in Texas in the magazine ``Texas Medicine'' outlines 
the success of the independent appeals process as part of the HMO 
reform. As the article references, a provision of the law has been 
particularly effective in providing patients with real protections.
  When the Texas legislature passed Managed Care Reform in 1997, it 
included an external appeals provision allowing patients to appeal the 
decisions of their health care plans. These appeals are not brought 
through expensive and time-consuming legislation but through quick 
reviews by State-certified independent review organizations called 
IROs.
  IROs are made up of experienced physicians who have the capability 
and authority to resolve disputes for cases involving medical judgment. 
Their decisions are binding on both the patients and the plans.
  These provisions have been successful, not only because they protect 
patients, but also because they protect the insurers. Plans that comply 
with the IRO's decision cannot be held liable for punitive damages. So 
if a decision goes against the patient, that patient can still go to 
court. But we will talk about that later on the lack of litigation 
under the Texas laws since 1997.
  This plan has worked real well. Since 1997, more than 1,000 patients 
and physicians have appealed the decisions of the HMOs. The 
independence of the process is demonstrated by the fairly even split in 
the decisions resulted. In 55 percent of the cases, the independent 
review organizations, the IRO, fully or partially reversed the decision 
of the HMO. So in 55 percent of the cases, they were found for the 
patient or the physician than the original decision.
  Now, during the debate on HMO reform in Texas, there was concern that 
managed care reform would be very costly and would lead to a flood of 
unnecessary and expensive litigation. But that has not been the case in 
Texas. To my knowledge, less than five cases have been filed since 
patients' protection became law in 1997.
  I believe that the external appeals process has been instrumental in 
the success of the Texas plan and has given patients what they really 
want, access to timely quality medical care while protecting insurers 
from costly litigation.
  The process works so well that, despite the U.S. Fifth Circuit Court 
of Appeals ruling that the external appeals were in violation of the 
ERISA, Aetna and other HMOs agreed to voluntary submit disputes to the 
IROs for resolution.
  Finally, Mr. Speaker, I would like to point out that these 
protections have not lead to dramatic premium increases as some of our 
naysayers said. In fact, in Texas, the premium increases have been 
consistent with, and in some cases actually lower than premium 
increases in other States with substantially weaker patient 
protections.
  Mr. Speaker, it is time for Congress to enact a Bipartisan Patient 
Protection Act. Our President is supporting it. Hopefully we will be 
able in the House and the Senate to put a plan together that will give 
patients the protections that they need. I urge my colleagues to join 
me in supporting it.
  Mr. Speaker, I include the article from the magazine ``Texas 
Medicine'' that I referenced earlier as follows:

                    [From Texas Medicine, Jan. 2001]

                      Second-Guessing the Insurers


            independent review process appears to be working

                            (By Walt Borges)

       Since late 1997, more than 1,000 Texas patients and 
     physicians have challenged decisions of health maintenance 
     organizations (HMOs), insurance companies, and third-party 
     administrators (TPAs) to deny payments for treatments that 
     the insurers deemed medically unnecessary or inappropriate. 
     The challenges were not brought through expensive and time-
     consuming litigation, but through quick reviews conducted at 
     no cost to patients and physicians by three state-certified 
     entities known as independent review organizations (IROs).
       A Texas Medicine analysis of Texas Department of Insurance 
     (TDI) statistics covering the first 2\1/2\ years of the IRO 
     system's operation found that the IROs reversed insurers' 
     decisions in whole or in part in more than 57 percent of the 
     1,007 cases that were reviewed.
       HMOs' decisions were reversed or modified in 55 percent of 
     the 515 reviews, while decisions by insurance companies and 
     TPAs were overruled in 60.5 percent of 481 reviews. Eleven 
     other reviews were for health care entities that did not have 
     an identifiable status in the TDI databases.
       Even though the TDI databases can be analyzed to show how 
     individual insurers fared in independent review, the findings 
     offer limited insights into the quality of care and decision-
     making because of large variations in the number of reviews 
     of each health care entity. Attempts to index the reversals 
     to claims or covered lives failed because of variations in 
     enrollment over the three-year period and because TDI does 
     not track the number of policyholders for health insurance 
     companies.
       ``There are a huge number of patients and a huge number of 
     claims, so reversal rates are tiny,'' said Paul B. Handel, 
     MD, of Houston, chair of Texas Medical Association's Council 
     on Socioeconomics. ``But only 8 to 10 percent of the cases 
     involve areas [of treatment] where the patients need the 
     [extensive] technology and medication. We should be looking 
     at how that population fares.''
       IROs were a key feature of a law passed by the Texas 
     Legislature in 1997 that gave Texas health plan members the 
     right to sue their HMOs for denying medically necessary 
     treatments. But unlike that controversial provision, which 
     acted as a lightning rod for insurance industry opposition 
     and prompted lawsuits claiming it conflicted with federal 
     law, establishment of independent reviews drew the public 
     support of consumer advocates, insurers, and doctors alike.
       In June, a three-judge panel of the U.S. 5th Circuit Court 
     of Appeals in New Orleans upheld provisions authorizing suits 
     against managed care organizations. However, the court ruled 
     that independent reviews of HMO decisions violated the 
     Employee Retirement Income Security Act (ERISA), the federal 
     law that reserves regulation of employer-funded benefit plans 
     to Congress.
       But the appeal of the IRO process is such that Aetna, whose 
     subsidiaries filed the suit, and other major HMOs announced 
     after the decision that they would continue to voluntarily 
     submit disputes to the IROs for resolution. That came well 
     before TDI told insurers and health plans that it would 
     consider the system intact until the completion of court 
     rehearings and appeals.
       Despite popular support for IRO process, some physicians 
     and IRO officials think many questionable decisions have been 
     left unchallenged because of a lack of public knowledge that 
     the system exists.
       ``The sense is that doctors and patients are not really 
     aware of the IRO process,'' said Dr. Handel. ``This is 
     something we've talked about at the council level.''
       Gilbert Prudhomme, secretary director of Independent Review 
     Inc., one of the Texas IROs, said he was ``absolutely 
     astounded how few people know about it.'' Mr. Prudhomme says 
     that as recently as last summer the insurance department at 
     The University of Texas M.D. Anderson Cancer Center was 
     unaware of the IRO process.
       ``A lot of people think ERISA preempts the system,'' said 
     Mr. Prudhomme. ``They tell

[[Page 1849]]

     me they didn't know if it was still valid or they thought it 
     had stopped working. There's a cloud over it by virtue of the 
     ERISA controversy.''
       IRO official Kathryn Block, administrator of Envoy Medical 
     Systems, said, ``The hospitals don't understand what we are. 
     They seem to think we're some kind of insurance company when 
     we ask for records.''

                                             REVERSAL RATES OF IROS
                                         [December 1997 to August 2000]
----------------------------------------------------------------------------------------------------------------
                                                                                                        Percent
                                                                                                        reversed
                      IRO                        Appeals     Upheld    Reversed   Partial    Percent     (total
                                                                                             reversed     and
                                                                                                        partial)
----------------------------------------------------------------------------------------------------------------
Texas Medical Foundation......................        652        308        301         43      46.17      52.76
Envoy Medical Systems.........................        273         98        159         16      58.24      64.10
Independent Review Inc........................         82         25         46         11      56.10      69.51
                                               -----------------------------------------------------------------
      Total...................................      1,007        431        506         70      50.25      57.20
----------------------------------------------------------------------------------------------------------------

                              how it works

       Texas was the first state with external review of medical 
     necessity decisions. Thirty-seven states now have a review 
     process. Under Texas law, a patient may seek review by an IRO 
     if a health insurer refuses to pay for treatment it considers 
     to be medically unnecessary or inappropriate. Patients or 
     their physicians also my request IRO reviews of denial of 
     treatments that are recommended but not yet performed. 
     Doctors cannot authorize the release of the medical records 
     needed for the review, however. Only the patient or a 
     guardian may sign the release form.
       In most cases, the health plan's internal appeals process 
     must be used before requesting an IRO appeal, Denial of 
     treatment for conditions that patients or doctors believe are 
     life-threatening may lead to a bypass of the insuer's 
     internal appeals process.
       The IRO process is not always available. A complaint to TDI 
     and/or an internal appeal to the health plan over the denial 
     of payment is the only challenge permitted when treatment 
     already has been provided and the insurer determines it was 
     not necessary or appropriate, or when payment for a service 
     not covered by the plan is denied. IRO appeals also are not 
     available when Medicaid, Medicare, or a Medicare HMO provides 
     a patient's health coverage.
       Insurers pay $650 for each review if the review is provided 
     by a physician and $460 if it comes from other health care 
     professionals, e.g., dentists, optometrists, and podiatrists. 
     The decision of the IRO is binding on the health plan or 
     insurer.
       Under TDI rules, ``the utilization review agent that 
     forwards an independent review request to TDI pays the IRO 
     that does the work,'' said TDI's Blake Brodersen, deputy 
     commissioner for HMOs. ``We believe that the utilization 
     review agents generally pass this cost through to the health 
     plans themselves. The IROs are certified by TDI after we're 
     satisfied they meet all certification requirements contained 
     in our rules. They do not, however, contract with TDI.''


                           But does it work?

       There is general agreement among regulators, IRO officials, 
     and health insurers that the system is working relatively 
     well for those who seek reviews.
       ``It's working very well and as the legislature intended,'' 
     said Insurance Commissioner Jose Monetmayor. ``The 
     legislature wanted a system of truly independent review, one 
     in which there were no foregone conclusions to favor health 
     plans or to favor patients. The independence of the process 
     is demonstrated by the roughly 50-50 split between decisions 
     upholding and decisions reversing adverse determinations by 
     health plans.''
       Phil Dunne, chief executive officer for the Texas Medical 
     Foundation (TMF), the first IRO certified by the state, said, 
     ``From TMF's perspective, the process appears to be working 
     in accordance with the statute and regulations. The various 
     organizations involved in appeals have been compliant and 
     cooperative.''
       Mark Clanton, MD, chief medical officer of Blue Cross and 
     Blue Shield of Texas, agrees. ``The process of independent 
     review appears to be working as intended in that it provides 
     an independent source of review for both consumers and health 
     plans,'' he said. ``Other than the additional cost of paying 
     for the appeals, the process is not burdensome; the 
     additional review provides members with additional choice.''
       Mr. Brodersen said TDI has received ``no complaints that 
     the process is burdensome to doctors. We have received a few 
     complaints from health care plans that we allow too short a 
     time for them to get patient records to the IROs.''
       He says he reviews completed between Nov. 1, 1997, and Oct. 
     31, 2000, could not have cost the health care plans more than 
     $718,250, ``plus the cost of copying medical records. 
     Obviously the plans incur other costs, such as those for 
     personnel time and shipping records. But nobody has attempted 
     to estimate these.''
       Lisa McGiffert of Consumers Union wonders whether patients 
     and physicians underutilize the system. Like Dr. Handel, she 
     is troubled by what she perceives as a lack of public 
     knowledge. She suggests that ``the state has the 
     responsibility to get individuals to know about the process. 
     It needs to be proactive in getting the information out.''

             Insurers and third-party administrators (TPAs) with the greatest number of IRO reviews
                                         [November 1997 to August 2000]
----------------------------------------------------------------------------------------------------------------
                                                                                                         HMO
             Insurer                    Other names              Type            Reviews completed    decisions
                                                                                                       reversed
----------------------------------------------------------------------------------------------------------------
Employers Health Insurance.......  ....................  Insurer.............  115.................           73
Blue Cross Blue Shield of Texas..  ....................  Insurer.............  94..................           52
American Medical Security........  ....................  TPA.................  23..................           11
The Prudential Insurance Company   ....................  Insurer.............  19..................            6
 of America.
PM Group Life Insurance Company..  ....................  Insurer.............  18..................            4
Texas Health Management Services.  ....................  TPA.................  17..................            9
CORPHEALTH, Inc..................  ....................  TPA.................  16..................            6
Aetna U.S. Health Care...........  Aetna, Aetna Life     Insurer.............  13..................            4
                                    Insurance Company
                                    and Affiliates.
CIGNA Behavioral Health..........  ....................  TPA.................  10..................            9
                                  ------------------------------------------------------------------------------
    Subtotal.....................  ....................  ....................  325.................          174
    Total for 64 other insurers    ....................  ....................  156.................           74
     and TPAs.
                                  ------------------------------------------------------------------------------
        Totals...................  ....................  ....................  481.................          248
----------------------------------------------------------------------------------------------------------------

       Insurers that deny payment for what they believe are 
     unnecessary or inappropriate treatments are required by TDI 
     to notify the patient that the IRO process exists twice in 
     the preauthorization process. But Ms. McGiffert notes that 
     the IRO process may appear to be just another frustrating 
     step to many patients who already have exhausted two levels 
     of insurers' internal appeals.
       Patients can be discouraged by multiple denials, she says. 
     ``They've been denied, they've appealed, and they've been 
     denied again. Why would they think the next one would be any 
     different?''


                       measuring quality of care

       The results of the independent reviews were compiled from 
     TDI databases. More than 230 records had obvious problems: 
     For example, HMO names were accompanied by insurance company 
     designations. Because the underlying records of the reviews 
     are not available to the public, TDI, at Texas Medicine's 
     request, corrected the questionable records by looking at the 
     records of each review.
       Texas Medicine split the 1,007 IRO decisions into two 
     groups for analysis. The first included the HMOs, while the 
     second included insurance companies and TPAs.
       Overall, denials by insurance companies and TPAs were 
     overturned 52 percent of the time, while IROs ruled the HMOs 
     made the wrong decision 49 percent of the time. (See 
     accompanying tables, pages 32-35.)

[[Page 1850]]

       However, 43 of 481 decisions involving insurers and TPAs 
     were partially reversed and partially upheld by the IROs. 
     Adding those figures into the mix yielded a full-and-partial 
     reversal rate of 55 percent. Similarly, 30 of 515 of the HMO 
     reviews resulted in full-and-partial reversals, for a mixed 
     reversal rate of 60.5 percent.
       The overall reversal rates and those listed for individual 
     companies say little about the overall quality of medical 
     care or of individual decisions to deny treatments, IROs and 
     insurers agree.
       ``The relatively small number of external appeals, when 
     compared with the millions of members and claims that go 
     through the system, reaffirms that there is no large-scale 
     problem with how plans apply their medical policy or how the 
     internal mechanism for reviewing member appeals works,'' said 
     Dr. Clanton. ``The principal conclusion is that the quality 
     of care remains very high in HMOs. Only 515 appeals were 
     filed, compared with millions of claims that were paid 
     according to member contracts. Further, only half of the 
     number appealed were reversed.''
       The numbers ``would probably not provide statistically 
     significant conclusions,'' Mr. Dunne said.
       ``It is important to note that IRO review is not a quality-
     of-care review,'' Mr. Dunne wrote in a response to Texas 
     Medicine's questions. ``The IRO is asked to determine if the 
     care is medically necessary, medically appropriate for the 
     setting of care, and/or timely (e.g., determining if other, 
     less invasive clinical interventions should be exhausted 
     prior to implementing the treatment plan that is being 
     appealed).''

----------------------------------------------------------------------------------------------------------------
                                                                                                      Decisions
                                                                                          Percent     fully or
                              Upheld                                 Split    Pending    reversed     partially
                                                                                                      reversed
----------------------------------------------------------------------------------------------------------------
37................................................................       5          3       63.48         67.83
34................................................................       8          1       55.32         63.83
9.................................................................       3          1       47.83         60.87
11................................................................       2          0       31.58         42.11
9.................................................................       5          0       22.22         50.00
6.................................................................       2          0       52.94         64.71
7.................................................................       3          3       37.50         56.25
6.................................................................       1          1       30.77         38.46
1.................................................................       0          0       90.00         90.00
120...............................................................      29          9       53.54         62.46
68................................................................      14          2       47.44         56.41
188...............................................................      43         11       51.56         60.50
----------------------------------------------------------------------------------------------------------------

                   good companies and bad companies?

       Texas Medicine's review of the IRO appeals outcomes did not 
     analyze how each of the Texas IROs handled the reviews of 
     individual insurers, TPAs, and HMOs. But Ms. McGiffert 
     suggested that annual trends sometimes show wide disparities 
     in reversals from the 50-50 rate the insurers and regulators 
     are prone to cite.
       TDI also puts some faith in the outcomes of reviews. ``We 
     monitor reversal rates along with the complaint statistics of 
     individual companies,'' said Mr. Brodersen. ``On occasion, a 
     high reversal rate has been one of the factors that led us to 
     perform quality-of-care examinations on particular 
     companies.''
       But he also noted, ``When you consider the huge number of 
     medical necessity decisions that HMOs make each day, 
     approximately 600 reversals over a three-year period suggests 
     that, overall, the quality of care provided by HMOs is very 
     good.''
       Officials with Envoy, which receives one of every three 
     referrals from TDI, say that a short-term analysis gives a 
     different picture than a long-term statistical analysis.
       Daniel Chin, managing director of Envoy, and his 
     administrator, Ms. Block, say they were initially asked to 
     review large numbers of physical medicine cases during the 
     year-plus period they have conducted reviews.
       ``Then all of a sudden, it was all psychological treatment 
     cases,'' said Mr. Chin. ``Now it seems we're getting physical 
     medicine cases again.''


                            iro consistency

       One analysis conducted by Texas Medicine was of the 
     reversal rates of the IROs. (See ``Reversal Rates of IROs,'' 
     page 31.) TMF had a reversal rate of 53 percent when both 
     full and partial reversals were taken into account. Envoy 
     reversed 64 percent of the decisions, and Independent Review 
     Inc. reversed partially or fully 70 percent of the insurers' 
     decisions.
       Does this suggest that the IRO process is inconsistent? Not 
     more than is expected when physicians exercise their 
     independent judgment on clinical problems, say regulators and 
     IRO officials.

                 RESULTS OF IRO REVIEWS OF HMO DECISIONS
                     [November 1997 to August 2000]
------------------------------------------------------------------------
                               Other names in TDI
             HMO                    database         Current affiliation
------------------------------------------------------------------------
Magellan Behavioral Health    ....................  ....................
Aetna U.S. Healthcare Inc...  Aetna Health Plan.    ....................
Aetna U.S. Healthcare of      ....................  ....................
 North Texas Inc
Texas Gulf Coast HMO Inc....  NYLCare Healthcare    Owned by Blue Cross
                               Plans of the Gulf     and Blue Shield of
                               Coast; NYLCare        Texas
                               Healthcare Plans.
Prudential Healthcare Plan    Prudential            ....................
 Inc.                          Healthcare.
United Healthcare of Texas    United HealthCare;    ....................
 Inc.                          United Behavioral
                               Health
Humana Health Plan of Texas   Humana; Humana        Humana merged with
 Inc.                          Health Plan; Humana/  Employers Health in
                               PCA Health Plans of   1997
                               Texas; Humana
                               Health Plans.
Harris Methodist Texas        Harris Methodist      ....................
 Health Plan.                  Health Plan; Harris
                               Health Plan; Harris
                               Methodist Health
                               Inc.; Harris
                               Methodist Health.
PacifiCare of Texas.........  PacifiCare..........  Part of PacifiCare
                                                     of Texas
Southwest Texas HMO Inc.....  NYLCare Health Plans  Owned by Blue Cross
                               of the Southwest.     and Blue Shield of
                                                     Texas
Rio Grande HMO..............  HMO Blue-El Paso;     Owned by Blue Cross
                               HMO Blue-West         and Blue Shield of
                               Texas; HMO Blue-      Texas
                               Northeast Texas;
                               HMO Blue-Southeast
                               Texas; HMO Blue-
                               Southwest Texas;
                               HMO Blue/formerly
                               NYLCare of the Gulf
                               Coast.
Scott & White Health Plan...  Scott and White.      ....................
CIGNA Healthcare of Texas     CIGNA Behavioral      ....................
 Inc.                          Health; CIGNA
                               Healthcare of Texas-
                               North Division;
                               CIGNA Healthcare of
                               Texas-South Texas
                               Division.
Texas Health Choice LC        ....................  ....................
Memorial Sisters of Charity   ....................  Now part of Humana
 HMO LLC.
SHA LLC.....................  FIRSTCARE Southwest   ....................
                               Health Alliances.
One Health Plan of Texas,     ....................  ....................
 Inc
Methodist Care Inc            ....................  ....................
AmeriHealth of Texas          ....................  ....................
Community First Health Plans  ....................  ....................
 Inc
Amil International (Texas)    ....................  ....................
 Inc
Healthplan of Texas Inc.....  Heritage Health       ....................
                               Plans
Amcare Health Plans of Texas  Foundation Health, A  ....................
 Inc.                          Texas Health Plan
Healthfirst HMO Inc.........  HealthFirst HMO;      Merged with
                               Healthfirst.          AmeriHealth of
                                                     Texas
AmeriHealth HMO of North      AmeriHealth HMO       ....................
 Texas.                        Texas; AmeriHealth
                               HMO.
Anthem Health Plan of Texas.  Anthem Group          Merged with
                               Services              AmeriHealth of
                               Corporation.          North Texas
Healthcare Partners HMO.....  ....................  Merged with
                                                     Healthfirst HMO
Principal Health Care of      ....................  Merged with United
 Texas, Inc.                                         HealthCare
------------------------------------------------------------------------


--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                HMO                                                            Percent
                    Current covered lives                        Reviews     decisions      Upheld       Split       Pending      Percent     with some
                                                                completed     reversed                                            reversed     reversal
--------------------------------------------------------------------------------------------------------------------------------------------------------
625,463......................................................            3            2            0            1            1        66.67       100.00
443,381......................................................           37           17           16            4            2        45.95        56.76
415,417......................................................           18           11            6            1            0        61.11        66.67
407,328......................................................           71           30           38            3            3        42.25        46.48
344,334......................................................           72           36           35            1            3        50.00        51.39
315,417......................................................           33           20           11            2            1        60.61        66.67
240,371......................................................           93           48           43            2            0        51.61        53.76
197,058......................................................            7            5            2            0            1        71.43        71.43
186,103......................................................           45           20           22            3            0        44.44        51.11
169,438......................................................           17            6            6            5            0        35.29        64.71
148,702......................................................            4            1            2            1            0        25.00        50.00
121,275......................................................            9            6            3            0            0        66.67        66.67
114,264......................................................            4            3            0            1  ...........        75.00       100.00
104,171......................................................            2            2            0            0            0       100.00       100.00
90,984.......................................................           13            8            5            0            0        61.54        61.54
49,097.......................................................            4            1            3            0            0        25.00        25.00
42,785.......................................................            2            1            1            0            0        50.00        50.00
40,363.......................................................           40           13           24            3            0        32.50        40.00
37,743.......................................................            2            0            1            1            0         0.00        50.00
10,898.......................................................            1            1            0            0            0       100.00       100.00

[[Page 1851]]

 
8,108........................................................            1            0            0            1            0         0.00       100.00
7,266........................................................           11            6            4            1            0        54.55        63.64
4,931........................................................            6            4            2            0            0        66.67        66.67
0............................................................           13            8            5            0  ...........        61.54        61.54
0............................................................            5            3            2            0            0        60.00        60.00
0............................................................            1            1            0            0  ...........       100.00       100.00
0............................................................            1            1            0            0            0       100.00       100.00
4,124,897....................................................          515          254          231           30           11        49.32        55.15
--------------------------------------------------------------------------------------------------------------------------------------------------------

       ``The IROs, by definition, are independent,'' said Mr. 
     Bordersen. ``However, each must do its review in conformity 
     with TDI requirements. We monitor processes, not results, and 
     at the present time we are satisfied that each IRO is doing 
     its work in accordance with our rules.''
       Mr. Dunne points out that the larger number of reviews 
     conducted by TMF could account for the discrepancy in 
     reversal rates.
       Ms. McGiffert says the discrepancy in reversal rates is not 
     unexpected, as physicians will make judgments that differ. 
     She says that TMF, which tends to have a more clinical 
     approach than the other two IROs, sometimes suggests other 
     alternatives for treating conditions that led to denied 
     claims, which she thinks is helpful to patients. TMF 
     officials say they may mention more conservative treatment 
     options in the clinical rationale they provide in upholding 
     insurer decisions, but they do not suggest treatment 
     alternatives.
       Dr. Handel say TMF's approach is appreciated. ``My sense is 
     that the patient may be benefiting from their suggestions. A 
     purely administrative type of appeal may not benefit the 
     patient as much.''
       Ms. Block noted that Envoy uses doctors who exercise 
     clinical judgment in their reviews, but they do not propose 
     treatment alternatives because that is not the function of 
     the review process.
       Mr. Prudhomme says physicians who conduct the reviews for 
     Independent Review Inc. are encouraged to refrain from 
     suggesting alternatives, unless it is obvious from the 
     records that another course of action would benefit the 
     patient.

                          ____________________