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Getting Basic Health Care Services & Medically Necessary Treatment from your Health Plan

Presenters: Lyn Gage, R.N. and Susan Burger

Family Voices of California

Brown Bag Lunch Training Series

April 7, 2010

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Be a Wise Patient

Take Responsibility for your own healthcare

• READ YOUR EVIDENCE OF COVERAGE

• Partner with your doctors

• Research to gain understanding

• Make objective decisions

• Ask an advocate to help you through difficult times

• Trust your intuition

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Be a Wise Patient (cont.)

Select Physicians wisely and communicate

effectively

• Write down questions and concerns

• Be truthful

• Make sure you understand before the physician leaves

• Ask for second opinions

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Be a Wise Patient (cont.)

• Follow your physician’s treatment plan

• If you encounter problems, report them immediately

• Know your medications

• Right medication, dosage, times

• Read inserts, know the indications and side effects

• Do your research

• Know what options you have

• Make sure resources are credible

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Your Treatment Requests

• Your physician requests authorization for your treatment

• A Medical Group, IPA, or Plan reviews the request and

• Approves - treatment authorized

• Disapproves – treatment not authorized

• You have the right to file an appeal of a denied treatment with your health plan

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Health Plan Grievances

• All health plans are required to provide a grievance appeal process

• To request an appeal:

- Submit the request in writing

- Phone request

- On line (plan’s website)

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Appeal Time Lines

• Expedited Appeal

- 72 hours (Has to meet legal criteria)

• Standard Appeal

- 30 days

• Decision - Uphold or Overturn

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The Service Denial

• Medical Necessity

• Experimental/Investigational

• Benefit Coverage

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Now What?

Department of Managed Health Care

California has the strongest patient's rights laws in the nation. The Help Center at the Department of Managed Health Care is here to explain your health care rights and help you understand how to use your health care benefits. We make sure that health plans follow the law and address member complaints on time.

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Our Goal: Getting the Right Care

at the Right Time

• Solvency of plans and providers

• Help Center for complaints & problems

• Monitor grievances and IMR process

• Monitor provider network terminations

• Proactive licensing of products

• Surveys and audits

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Dual Regulation – Unique to California

DMHC Regulates All HMOs and certain PPO products for Blue Shield and

Anthem Blue Cross PPO products (Blue Shield and Anthem Blue Cross) Specialized plans Prescription Drug Plans (PDP) (by agreement with the

California Department of Insurance (CDI) Must cover all medically necessary basic health care

services

CDI Regulates Most PPOs Most EPOs Most Indemnity products No HMOs 1.3 million PPO enrollees May carve out or limit benefits (e.g. no maternity care)

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Health Care Rights

You have the right to:

• Receive care when you need it

• Have an appointment when you need one

• Have an appointment with a specialist when you need one

• Have continuity of care if your doctor or medical group leaves your plan

• Receive treatment for certain mental health conditions

• Get a second doctor’s opinion

• Know why your plan denies a service or treatment

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Health Care Rights

You have the right to:

• Understand your health problem

• File a complaint and ask for an IMR

• Choose your own doctor (within network)

• See your medical records

• Keep your medical information private

• Have an Advanced Directive

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What is the Help Center?

• The Help Center provides assistance to consumers regarding their health plan problems or questions

• We review issues and make certain that plans follow the law and provide the care that members are entitled to

• After-hours answering service available: • Urgent matters handled by on-call

personnel• Our staff are consumer rights experts, health

care professionals, analysts, and attorneys who:• Educate a caller on DMHC jurisdiction• Identify a caller’s needs for appropriate

resolution and/or referral

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What is the Help Center? (cont.)

• Educate a caller on the health plan’s grievance process, as well as DMHC’s complaint process

• Contact health plans for quick resolution of consumer grievances, if appropriate

• Provide information and referrals to other agencies, when appropriate such as to the Department of Insurance, Department of Health Care Services, Federal Department of Labor

• Assist callers in completing DMHC complaint forms

• Send out educational materials such as complaint process brochures and fact sheets

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Help Center Services

The Call Center

• Telephone lines are open 7:00 a.m. to 7:00 p.m. Monday through Friday (1-888-466-2219)

• Answering service is available after-hours, on weekends and holidays

• Dedicated lines for the deaf (CA Relay Service for the Deaf) (1-877-688-9891)

• Assist Consumers in 150 languages• Employ bilingual staff• Use interpreter services

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Quick Resolution

• Swiftly handle routine issues between the health plan and enrollee

• Generally, a three-way conference call between call center staff, a representative of the health plan, and the enrollee takes place

• Issues are resolved within 1 to 2 days

• More complex issues are sent through the normal complaint process

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Urgent Complaints

• Urgent complaints involve issues that need immediate resolution

• These issues cannot wait 30 days to be resolved

• Urgent complaints generally involve:

• Denials in filling prescription medications

• Delays in obtaining appointments

• Surgery for pressing health issues

• Premature release from the hospital

• Inability to obtain a referral for treatment

• Urgent complaints are referred to the clinical staff who works with the consumer and the health plan to resolve the issue

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Standard Complaint Resolution

The Standard Complaint Resolution process handles consumer complaint issues related to:

• Quality of Care

• Continuity of Care – Early Review

• Financial/Claims and Billing

• Benefit Coverage Disputes

• Eligibility; Enrollment; Disenrollment – Early Review

• Inadequate Access to Care

• Attitude or Service Concerns

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Standard Complaint Resolution(cont.)

• By law, consumers must complete their health plan’s grievance and appeals process prior to filing a Standard Complaint with the DMHC except for Early Review issues• Standard Appeal: Can take up to 30 days to

resolve• Expedited Appeal: Must be resolved within

72 hours• Consumers receive all resolutions from their

health plan in writing [with the exception of “exempt” grievances resolved by the next business day in accordance with Health and Safety Code Section 1368(a)(4)(B)].

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What is an Independent Medical Review – IMR?

• The IMR process is intended to resolve medical necessity, reimbursement for emergency services, and experimental/ investigational disputes only

• For example, if your health plan denies you health care services on the basis that the service is not medically necessary, you can request an IMR

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Who is entitled to an IMR

You may request an IMR if:

• The service or treatment you have been denied is a covered benefit

• You requested a medically necessary treatment and received a decision from your health plan that denied, delayed, or modified the treatment as not medically necessary; or if . . .

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Who is entitled to an IMR (cont.)

• . . . The service or treatment is denied as experimental / investigational; or

• Reimbursement for emergency / urgent care is denied and . . .

• It has not been over six months since you received the denial

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Who is Not Eligible for an IMR

• A Medicare beneficiary

• A Medi-Cal fee for service recipient

• A Medi-Cal managed care enrollee that has filed for a Fair Hearing with the Department of Health Care Services

• An enrollee of a self-insured plan or ERISA (Employee Retirement Income Security Act of 1974) plan

• An enrollee who is disputing a worker’s compensation claim

• Treatment denied because it is not a covered benefit

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How to Apply for an IMR

• Complete an IMR application• The application may be obtained by calling the

DMHC’s Help Center at 1-888-466-2219, or • Go to the DMHC’s web site:

www.healthhelp.ca.gov

• An IMR application may be accompanied by any relevant material or documentation including:• Medical records (including out-of-network

providers)• A copy of the health plan’s denial letter• A statement from your provider establishing that

the dispute is eligible for review• A statement from your provider indicating that

the service or treatment request is medically necessary

• Medical articles of support

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How to Apply for an IMR (cont.)

• Be specific about treatment requested

- Include any dates of service

- Payments made

- Name of in-network or out-of-network provider (Note: a health plan is not obligated to provide out-of-network services if a qualified in-network provider is available.)

- Extenuating circumstances (example: no network provider available)

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IMR Qualification Process

• The Help Center reviews the health plan’s grievance resolution of the disputed treatment

• IMR application reviewed by assigned analyst, clinical staff and legal counsel to determine benefit coverage and qualification for the IMR process

• Cases disqualified due to benefit coverage are converted to a Standard Complaint for resolution

• Qualified IMR applications are sent to the contracted review organization

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What Happens When an IMR Decision is Rendered ?

• The decision is reviewed and then adopted by the DMHC

• Once the decision is adopted, the decision becomes FINAL and cannot be appealed by either the enrollee or the health plan

• The decision is sent in writing to the

• Enrollee

• Enrollee’s physician

• Enrollee’s health plan

• The health plan is required to fully comply with the decision

• Overturned decisions: The health plan must provide authorization for the service or treatment within five business days

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Division of Plan Surveys

MEDICAL SURVEYS –

Routine – at least every 3 yrs

Survey areas include:

• Quality Management

• Access and Availability

• Grievances and Appeals

• Utilization Management

• Continuity of Care

• Prescription Drugs

• Access to Emergency Services and Payment

Non-Routine - as needed

Surveys may be initiated by:

• Whistleblower Activity

• Large number of Help Center complaints

• Findings during routine surveys

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Where to Get More Information

• California Code of Regulations, Title 28, Division 1, Chapter 1 (Sections 1300.43 – 1300.826)

• Knox-Keene Health Service Plan Act of 1975 (Health and Safety Code Sections 1340 – 1399.818)

• DMHC website at: www.healthhelp.ca.gov

• DMHC’s Help Center at 1-888-466-2219