Challenging Health Care Decisions!
OLD WAY v. NEW WAY
- Traditional indemnity insurance (self pay)
- Medical service provided
- Bill submitted to insurer by physician
- Payment forwarded
PROSPECTIVE, CONCURRENT AND RETROSPECTIVE REVIEW
- Prior approval for care provision
- Review at time care is provided
- Review after care is provided
- Financial risk to beneficiary and provider
BENEFITS COVERED
- Commercial health benefits
- Publicly funded benefit programs
- MEDICAID
- MEDICAR E
- Managed Care Programs
- HealthChoices
- Commercial Benefit Programs
NEW LAW
QUALITY HEALTH CARE ACCOUNTABILITY ACT OF 1998
- Effective January 1, 1999
- Known as "ACT 68"
- No final regulations to date
SCOPE AND COVERAGE
- All "managed care plans"
- Gatekeeper
- Integration of financing and delivery of benefits
- Incentives to enrollees to use network providers
WHO’S IN AND WHO’S OUT
- IF THEY FUNCTION AS AN MCO:
- HMOs
- PPOS
- Hospital plan corporations (BC)
- Professional service corporations (BS)
- Governmental units
- HEALTHCHOICES PROGRAM
HISTORY: HEALTHCHOICES PROGRAM
- Begun in 1997
- Existing grievance requirements set by HCFA and RFPs
- Review by DPW and/or DOH
THREE LEVELS OF REVIEW
- First Level Review within MCO
- Second Level Review within MCO
- External DOH Review
- MA "fair hearing" review by DPW
- Possibility of inconsistent results
WHAT CAN BE REVIEWED
- Any determination which denies service or prescription or reduces or changes service or prescription ordered
SPECIAL HEALTHCHOICES FEATURE
- Service must be continued during pendency of grievance and review if:
- Appeal filed within 10 days
- Special provisions for prescription drugs
- Three day supply at outset
- Fifteen day supply of ongoing medication
IMPACT OF ACT 68
- Overlays new requirements on all managed care plans, including HealthChoices
- Review by competent peers
- Prompt and timely review
- Prompt payment of claims
- Provisions for expedited review
- Specific definition of "grievance"
GRIEVANCE
- Request by enrollee or provider with written consent
- Challenge to decision as to the medical necessity of the service
- Based on the PLAN’s definition of medical necessity
DOH EXAMPLES
- Denial of request for emergency service
- Denial of referral out of plan
- Denial of specialist referral
- Denial of non-formulary drug
- Denial of requested service duration
COMPLAINT
- Dispute or objection as to a provider, coverage by plan, exclusions, or anything else not related to medical necessity
- Not available to a provider
TIME FRAMES
- No rule as to time for denial
- But, clean claims to be paid in 45 days
- 30 days at First Level
- 45 days at Second Level
- 5 days to convey decision
- Independent Review
EXTERNAL AND EXPEDITED REVIEW
- By enrollee or provider with written consent
- Review by randomly selected external UR organization under contract with DOH
- Peer review by specialty and service
- Tight time frame 15/5/15/60 days
- 2 day fast track review by DOH after plan review
HOW IS IT WORKING?
- No regulations yet and media outcries at serious lapses
MEDICARE PART A AND B APPEALS
- Provider v. beneficiary rights
- Extent of levels of review
- Amount in controversy
- Rules of evidence
- Time frames for exercising rights
- Waiver of liability
IMPUTED KNOWLEDGE
- Did or could the beneficiary or provider know or reasonably be expected to know that coverage would be denied?
- If so, no liability for beneficiary but potentially no payment to provider anyway
PART A DECISIONS BY FI
- Is it a covered item or service?
- Amount of coinsurance
- Number of covered service days
- Number of home health visits
PART B DECISIONS BY CARRIER
- Is it a covered service?
- Reasonable charges by provider
- Imputed knowledge
PART A REVIEW PROCESS
Three Steps
- Initial determination by FI
- Reconsideration of initial determination by FI
- ALJ Review
- Appeal to federal district court
PART B REVIEW
Four Steps
- Initial determination by carrier
- Review of initial determination by carrier
- Carrier hearing
- ALJ review
- Limited court review
PEER REVIEW ORGANIZATIONS
- HCFA contractual relationships
- Required by Social Security Act
- Regular reviews to verify claims to Medicare
- Medical necessity
- Adequacy and completeness of care
- DRG coding
PRO DETERMINATIONS
- Lack of medical necessity
- Services not reasonable
- Inappropriate level of care (inpatient v. outpatient)
- DRG assignment
PRO PROCESS
- Notice to beneficiary and provider of intended initial determination
- Discussion to resolve between PRO physician advisor and provider
- Notice of determination to beneficiary, provider, and FI or carrier
SUBSEQUENT RIGHTS TO REVIEW
- Reconsideration by PRO in some circumstances
- Beneficiary may challenge only non-coverage
- Provider may challenge any lower DRG change
- Either may challenge medical necessity
RECONSIDERATION
- Review by independent physician advisor
- New evidence may be submitted
- Decision within 30 days
- Detailed response and description of rights
ALJ HEARING
- Beneficiary right
- At least $200
- Within 60 days of reconsideration
- Delegation to provider?
PRACTICAL ADVICE
- Dynamic, fluid, often chaotic process
- Be patient
- Educate respectfully the PRO, ALJ, etc
- Make it easy
- Recognize that due process has its limits
CONCLUSION
- Most managed care and other review determinations are based on specific medical facts as compared with specific medical necessity standards
- Have the facts and the record to support the claim if possible
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