California Department of Managed Health Care Tom Gilevich

1. California Department of Managed Health Care Tom Gilevich “Independent Medical Review (in Health Care Delivery Systems)” May 2, 2003 Los Angeles, California

2. Independent Medical Review - IMR • (External review) • An informal resolution of selected disputes over health care services from an HMO, health insurer or other third-party payer • Impartial and independent • Dispute-specific assessment • The last informal process available

3. Treatment Authorization Process Initial DenialInternal Grievance & AppealAfter the plan has its shot ….. Complaints to Dept. of Managed Health Carewww.hmohelp.ca.gov HMO Helpline: (888) HMO-2219

4. Purpose of IMR • “Restoring confidence in managed care” • Consumer demand for safeguards • Public policy accommodation • Industry acceptance • 42 states; Medicare; TRICARE

5. California IMR system (Cont’d) • Written determinations by reviewers provided • to all parties • Adopted by DMHC and binding on plan • Civil action against plan requires exhaustion of IMR process

6. California IMR systemThree types of disputes are eligible: - Experimental denials - Medical necessity denials - Denied reimbursement for emergency/urgent servicesNot coverage issues – plan determinations based on a finding the disputed services are not medically necessary.

7. California IMR system (Cont’d) • Completed internal grievance system • One page application – no cost to applicant • No threshold for amount in dispute • Department determines eligibility • State contracts with review organizations • Health plan provides information • Qualification & conflict screening of reviewers

8. Distinctions among IMR systems • When is it available – what does it decide • Automatic or application • Control, payment and administration • Reviewer selection • Standards & evidence used • How does it work – “due process” • Review and monitoring or reviews • Consequences if not utilized