Transcript Just for you! - Family Voices of California

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
1
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
•
2
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.)
•
•
•
•
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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
Help Center Services
The Call Center
•
Telephone lines are open 7:00 a.m. to 7:00
p.m. Monday through Friday (1-888-4662219)
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:
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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
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
•
•
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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
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Non-Routine - as needed
Surveys may be initiated by:
• Whistleblower Activity
• Large number of Help
Center complaints
• Findings during routine
surveys
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
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DMHC’s Help Center at 1-888-466-2219
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