Most Consumers Unaware of Safeguards Against Health Plan Influence in Independent Medical Review Process.

News Editors/Health/Medical Writers

OAKLAND, Calif.--(BUSINESS WIRE)--May 1, 2003

California HealthCare Foundation Report Looks at Experiences with

1999 Law, Recommends Improvements in Process

California's independent medical review (IMR) process was designed to be free of health plan influence, but patients and physicians are often unaware of its built-in safeguards and protections, according to a new study (www.chcf.org) conducted by the Institute for Medical Quality (IMQ) for the California HealthCare Foundation (CHCF).

Over 1,700 California patients have taken advantage of the 1999 law which entitles patients to an external, independent review by medical experts after they have exhausted a health plan's internal grievance process, or if 30 days have passed since the denial. Patients denied treatments for investigational or experimental reasons are not required to go through internal review. According to DMHC statistics, 36 percent of health plan denials were overturned in 2001 and 2002.

"Two-thirds of patients did not know that medical experts had no significant financial interest in the patient's health plan and that findings had to be supported by medical and scientific evidence," said Jill Silverman, MSPH, president and CEO of IMQ. "Seventy percent of physicians did not know if the health plan played a role in selecting the medical experts for the IMR."

"Only about half of respondents felt confident or very confident that consideration was given to their individual medical status, that the review was impartial, that consideration was given to all available scientific information and that individual reviewers had appropriate expertise," Silverman said.

When requested by a patient, the external review of a health plan treatment denial is conducted by an independent review organization that contracts with the Department of Managed Health Care, which has managed the program for consumers since 2001.

The study, "Independent Medical Review Experiences in California, Phase II: Cases Including Medical Necessity," reviewed the experiences of patients, physicians and health plans with IMR during 2001 and identified several ways in which the external review process might be improved.

Patients, health plans and physician respondents all felt that the external review process should be more open to patients and physicians and that more should be known about reviewers' qualifications. The report recommends:

-- Notifying patients of what information is sent to the

independent review organization (IRO).

-- Requiring the IRO to contact the patient to verify that the

correct records are being reviewed.

-- Advising the patient of the reviewer's specialty before the

review begins.

-- Considering more than one expert on a panel so that different

views are represented.

-- Giving the patient's physician access to the reviewer to

discuss the case.

Based on written surveys and follow-up interviews, nearly three-quarters of patients believed they had a 50/50 chance of having their health plan denial overturned. In fact, during the 2001 study period 37 percent of all health plan denials were overturned. (www.dmhc.org) Physicians did not share their patients' optimism: only 33 percent of physicians thought chances were good that a patient's denial would be overturned.

An unexpected finding from follow-up telephone conversations was a perception among a number of surveyed patients regarding personal difficulties receiving an IMR-approved service or having it paid for by their health plan. All but one of the health plans report they have a process in place to verify that IMR decisions are implemented, as does the DMHC. Once learning of these results, the DMHC initiated its own inquiry to determine if a service or treatment had in fact been provided or paid as required.

All the health plans, except one, reported that results of recent IMR cases had influenced internal medical policy and coverage decisions, particularly related to Bariatric (gastric bypass) surgery, drug criteria, breast surgery, chiropractic and physical therapy treatments, and oral maxillofacial procedures.

In other findings:

-- Patients may be staying in the health plan grievance process

longer than necessary. Only half of surveyed patients reported

completing the health plan process within the 30-day limit.

-- The relatively low number of IMR cases -- less than one

percent of managed health care members -- may be due to the

difficulty of the path to IMR that goes through the health

plan's denial process. In five health plans where data was

available, only 3 to 25 percent of cases potentially eligible

for IMR were filed.

-- Two-thirds of patients were not aware of IMR as an option

before their direct involvement and three-fourths of their

physicians were unaware of the process until it was actually

needed.

-- The seven health plans (representing 94% of California IMRs

completed in 2001) in the study were cited by patients as the

most frequent source of knowledge about IMR, but not all of

these plans reported including IMR information in all places

required by law.

-- Sixty percent of patients were satisfied with the amount of

time it took to receive the results of the IMR and a slightly

higher percentage realized that the DMHC was involved in the

process.

-- Patients with investigational/experimental treatment decisions

were less confident in the IMR process than patients who had

cases related to "medical necessity."

-- Following the IMR, a patient's confidence that their health

plan covered medically necessary services depended on whether

their denial was overturned or upheld. Sixty-three percent of

those with denials overturned by IMR said the process

increased confidence, while 89 percent of those whose denials

were upheld said that their confidence had decreased.

The report includes additional recommendations for improving the quality of IMR and making it more accessible and efficient for consumers, physicians, and health plans. These include:

-- Formalize steps leading up to IMR and advising patients at the

beginning of the grievance process that they may apply for IMR

if the case is unresolved after 30 days.

-- Focus IMR notification and instructions in denial letters and

give simple clear steps that patients can take after receiving

a denial.

-- Assist patients in submitting information to the review,

especially those with investigational/experimental cases, and

in locating information to support their case.

-- Provide patients with information that helps them clearly

understand reasons for the IRO decision.

-- Provide follow-up support for patients by verifying that the

decision was implemented.

-- Develop effective ways to inform physicians of the

availability of IMR.

-- Offer health plans information to understand the criteria and

literature used to make IRO decisions.

-- Provide patients with a simple "How To" guide outlining appeal

and IMR steps.

-- Provide adequate feedback to and monitoring of IROs to ensure

a quality process.

Utilizing a written survey and telephone interviews, the Phase II study reviewed the experiences of 610 patients whose cases went through IMR in California during 2001. For additional information on survey methodology and for background on the history of IMR law, please see the report.

The full report can be viewed at www.chcf.org.

The Institute for Medical Quality (IMQ) is a 501 (c) (6) non-profit organization dedicated to improving the quality of care provided to patients across the continuum of health care. IMQ offers a wide range of educational, accreditation, consultation, and certification programs.

About the California HealthCare Foundation

The California HealthCare Foundation (CHCF) is an independent philanthropy committed to improving California's health care delivery and financing systems.