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New Maine Law Sets Health Insurance Medical Review Standards

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A new law in Maine could change how health insurance company medical reviews in that state work.

Maine Gov. Janet Mills, a Democrat, recently signed Legislative Document 249, a bill that requires insurance company medical reviews to be conducted by medical professionals.

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Under the new law, which is set to take effect Sept. 17, “an appeal of a carrier’s adverse health care treatment decision must be conducted by a clinical peer.”

The appeal must be handled by a licensed health care practitioner board certified in the specialty that would typically manage the medical condition, procedure or treatment under review, or board certified in a similar specialty, according to the text of the new law.

The reviewer’s compensation cannot directly or indirectly depend upon the “quantity, type or cost of the medical condition, procedure or treatment that the physician or other licensed health care practitioner approves or denies on behalf of a health insurance carrier” according to text of the new law.

‘An Unfair, Heartless Practice’

Mills said in a statement about the new law that she herself has had experiences with claim denials.

“After my late husband Stan suffered a stroke, insurance companies would sometimes deny claims for care without any explanation,” Mills said in the statement. “It is an unfair, heartless practice that puts profits ahead of the patient’s well-being… Medical professionals with the same training as the patient’s own doctor should be conducting medical reviews for claims, not an insurance company official.”

The History

The bill was introduced by state Sen. Geoffrey Gratwick, D-Bangor, a retired doctor who ran arthritis clinics.

The state House and the state Senate passed LD 249 unanimously in May.


A description of the law is available here.

The law’s legislative history is available here.

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