Supreme Court Hears Landmark HMO Case Brought by Speech-Language Pathologist In January, the U.S. Supreme Court heard arguments in a landmark case about a patient’s right to have an independent medical review if a health maintenance organization (HMO) denies coverage of care. The patient—and plaintiff—in the Supreme Court case is Illinois speech-language pathologist Debra Moran. The court’s ruling, expected by ... On the Pulse
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On the Pulse  |   March 01, 2002
Supreme Court Hears Landmark HMO Case Brought by Speech-Language Pathologist
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Practice Management / Professional Issues & Training / On the Pulse
On the Pulse   |   March 01, 2002
Supreme Court Hears Landmark HMO Case Brought by Speech-Language Pathologist
The ASHA Leader, March 2002, Vol. 7, 1-12. doi:10.1044/leader.OTP.07042002.1
The ASHA Leader, March 2002, Vol. 7, 1-12. doi:10.1044/leader.OTP.07042002.1
In January, the U.S. Supreme Court heard arguments in a landmark case about a patient’s right to have an independent medical review if a health maintenance organization (HMO) denies coverage of care. The patient—and plaintiff—in the Supreme Court case is Illinois speech-language pathologist Debra Moran.
The court’s ruling, expected by July, could determine to what extent states can regulate managed care. At issue is whether state laws regulating managed care are overruled by the federal Employee Retirement Income Security Act, which was designed to provide uniform regulation for multistate employee benefits. Passed in 1974 before managed care became prevalent, the federal law is silent on whether insurers are required to provide independent medical reviews.
In recent years, an increasing number of states have backed patients’ rights through laws that give patients the right to ask for a medical review. Since 1987, Illinois has offered an independent review provided by a specialist selected by the HMO and the primary-care physician. If the outside reviewer says the service is medically necessary, the HMO must cover it. But Moran’s insurer, Rush Prudential HMO, refused to pay for a surgery after an independent medical review deemed it necessary.
Moran’s legal battle began in 1995 when she began to feel pain and numbness in her right arm. In her private practice, which focuses on serving children and adults who use augmentative and alternative communication, Moran said the pain made it difficult to drive, type, and talk on the phone. “I would drive anywhere from five minutes to an hour to see a patient for a speech-language evaluation, take notes, and then drive back and type a 15-page evaluation,” she said.
An orthopedic surgeon diagnosed Moran with carpal tunnel syndrome, and she had surgery in August 1996; but the pain in her neck, shoulder, and arm intensified, and Moran had to gradually reduce her caseload.
An orthopedic surgeon then diagnosed her with brachial plexopathy, a condition in which there is damage to the brachial nerve that leads to the arm. Her physician referred Moran for physical therapy and a support group. But her pain worsened, and by mid-1997 her physical therapist said there was nothing more that she could do.
Through a physical therapist friend, Moran found Julia Terzis, a microreconstructive surgeon who specializes in brachial plexopathy. Moran paid out-of-pocket for an evaluation by Terzis who diagnosed her with brachial plexopathy and a related condition, thoracic outlet syndrome (TOS), which can impair circulation and neural transmission. She recommended surgery to remove the compression and repair possible nerve damage.
Moran returned to her primary-care physician and requested a referral to Terzis, who was out of network. Her physician asked Moran to get a second and third opinion from in-network surgeons. Both recommended a standard surgery for TOS. One surgeon indicated a one-third chance of not getting better and a one-third chance of being paralyzed.
Moran didn’t like the odds. “They were not going to deal with the nerve damage,” she said. Moran’s physician wrote the referral to Terzis—and the next day the HMO denied it. Moran pursued the internal appeals process with the insurer to no avail.
By 1998, Moran reduced her caseload to about three patients a day. “I couldn’t cook, clean, lift a fork by myself, or hand write a postcard,” she said.
Instead of waiting years for the case to be fought in court, Moran’s husband encouraged her to undergo the surgery. The 14-hour microreconstructive surgery cost $95,000. Moran paid for the surgery in advance by borrowing from her husband’s 401(k) plan and her mother-in-law and maxing out their credit cards.
The procedure saved Moran’s career and quality of life, and today she is pain-free. Almost a year later, the state court ordered the insurer to provide her with an independent medical review, which deemed the surgery medically necessary. Moran amended her suit, asking the HMO to reimburse her for the surgery.
Rush Prudential HMO won in federal district court, but the U.S. Court of Appeals in Chicago sided with Moran, and Rush Prudential HMO appealed to the U.S. Supreme Court.
The time-consuming legal case affected Moran’s private practice as she traveled to Springfield to advocate for patients’ bill of rights legislation, but her clients have been supportive. “The families have always been willing to reschedule, “ Moran said.
Ultimately, Moran’s case could help other SLPs help their patients fight for coverage. “More often than not, health insurance policies say that speech-language pathology services are limited in coverage,” she said. “We need to know where to refer patients so they can pursue coverage by obtaining an independent review.”
Amicus briefs have been filed by 32 states and the American Medical Association in support of her case.
To learn more, visit Moran’s Web site at http://www.empiimp.com/moran/index.html or contact her by email at deb@ntsource.com.
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March 2002
Volume 7, Issue 4