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