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
  • Com mercial 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
  • Hos pital 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