Missouri High Court Upholds State’s Right to Question Doctors about Managed Care Coverage Decisions

The Missouri Supreme Court ruled April 10 that the state has the authority to question doctors about denial of care decisions they make on behalf of managed care companies, the Kansas City Star reports. The case was prompted by a 1999 dispute over the "medical necessity" of an oral surgical procedure that was denied by St. Louis-based Prudential Health Care. After the denial, the oral surgeon filed a complaint with the State Board of Registration for the Healing Arts, which issued a subpoena to question Prudential Medical Director Richard Fallon. Fallon refused to appear before the board, saying the state did not have the authority to review decisions made on behalf of managed care companies. The case went before the Cole County Circuit Court, which ruled in favor of the board. Fallon appealed to the state Supreme Court, which upheld the lower court's ruling. Aetna, which acquired Prudential in August of 1999, took over defense of the case and is "evaluating ... its next step." Robert Kremer, an Aetna spokesperson, said that courts in other states have issued rulings that conflicted with the Missouri Supreme Court decision (Karash, Kansas City Star, 4/11).