Know Your Rights for Senior Plans

In October of 1999, the House of Representatives passed a bipartisan patient protection bill that dramatically expanded a patient's right to sue a health plan if injured as a result of a denial of care or a delayed benefit coverage. Managed care organizations (MCOs) around the country took notice of this significant change in public sentiment and began revisiting their complaints, appeals policies and procedures, scrambling to provide external appeal options for their members to avoid potential future litigation.

MCOs that offer any type of senior plans have always had an external appeal option available to their members as part of Medicare. The Center for Health Dispute Resolution (CHDR) is the external entity MCOs must notify when appeals are generated. The center is charged with filing, making determinations and tracking appeals involving Medicare beneficiaries. In addition, any MCO that offers an HMO senior plan, often referred to as a Medicare + Choice product, is regulated further by the National Committee for Quality Assurance (NCQA), established to oversee quality assurance in managed care plans. The NCQA evaluates a number of factors regarding members' rights and responsibilities during the accreditation process, such as how clearly the MCO informs its members about how to get care and use its services, and how well the organization responds to members' complaints and appeals.

As part of their regulatory provisions, managed care organizations must provide written materials in the form of handbooks, certificates or other printed information (sometimes found on the back of a billing statement) that outlines the process for complaints and appeals for each line of business the organization provides, including any of the MCO's Medicare + Choice products. The following discussion is greatly simplified to illustrate how a managed care complaint and appeals process works, not just for senior plans, but for managed care members in general.

Complaints are the first level of entry into the appeals process. Generally, complaints are of two types: 1) related to benefits of the plan; or 2) related to quality of care. If the complaint is about a plan benefit (e.g., eye exam coverage, number of treatments allowable from a specialist), information about the member's particular plan is reviewed and a determination is made to allow or deny the request based on what that member's coverage allows. Once a determination is made, the member is notified of the findings and the benefit is either paid or denied. If the benefit is denied, instructions are provided in the letter to the member regarding the appeal process.

If the complaint is a quality-of care issue (e.g., questionable procedures, communication, access or availability issues), an investigation is conducted to determine the facts. A determination is made after reviewing the provider's response, medical records and progress notes, and facility and community standards for similar issues. The member is notified of the determination, and the case is deemed resolved. Most quality-of-care issues don't get to the appeal process unless the member brings forth significant additional information not available or submitted with the original complaint.

As mentioned earlier, when the member receives a denial or unfavorable determination, appeal instructions are included. In some HMOs, provisions are made for an "individual consideration" when unusual circumstances may dictate that it is in the plan's best interest to allow an exception.

An appeal is a complaint elevated to the next level. Generally, these are still handled internally by the HMO and a similar "complaint process" occurs. There is usually a specialist assigned to the file. Information is researched, data is collected, and the file is prepared to be presented to another individual or group within the organization that was not previously involved in the first determination. It's important to mention that the terms "appeal" vs. "grievance" may vary depending on the line of business, the regulatory agency, or whether the provider is a participating provider or not. It is at this first level of appeal that Medicare + Choice plans and regular Medicare plans must notify the external entity, the Center for Health Dispute Resolution (CHDR), of the appeal. The CHDR reviews the health plan's denial and makes a determination, notifying both the member and the health plan of their findings. If the determination is favorable to the member, the health plan must reverse their denial and provide proof to CHDR that they have followed through on the reversal. They may also choose to uphold the health plan's denial. CHDR also tracks and trends health plan appeals for Medicare.

Appeals may also proceed to a second or formal level within the MCO, which once again includes researching and collecting information and preparing the file for yet another committee or body within the organization. A final appeal step may include arbitration, enlisting the aid of the insurance commissioner or seeking settlement in the courts. Recent legislation may soon allow members the option of seeking the determination from an external review organization (ERO) earlier in the process.

If you would like further information regarding this discussion, I suggest visiting www.healthappeal.com on the internet. Aloha for now.