Rob Andrews: “There is another grave danger here. And, that is, that the HMOs will certainly take the position that even if there is…”

“There is another grave danger here. And, that is, that the HMOs will certainly take the position that even if there is not an explicit statutory definition of medical necessity in State law, that the State laws which permit them to incorporate their insurance companies carry with them the implicit right of the HMOs to fix by contract the definition of the terms of their contract. To sort of unpack that and put it in less legalese, they will take the position that State laws implicitly give them the right when they organize themselves to declare what definitions in their contracts mean, that it is a matter of contract. And I assure you that every HMO worth its salt will then put a boiler plate clause in their contract that says medical necessity means whatever we say that it means. So if your child's pediatrician thinks that it is medically necessary for your child to have an MRI but the reviewer for the HMO does not think so because the statistics show that very few 7-year-olds have a tumor problem, the HMO wins. That is a loophole that is very subtle but very disingenuous and very dangerous.”