Massachusetts Office of Patient Protection
On April 25, 2002, Karen Granoff, Director of the Massachusetts Office of Patient Protection, was the featured speaker at that month's CRC Presentation.
The Massachusetts Department of Public Health's Office of Patient Protection (OPP), established January 1, 2001, offers Massachusetts residents certain protections around managed care. OPP develops regulations, monitors the internal appeal process for compliance with the law, and administers the external appeal process. OPP also assists consumers with questions and issues regarding managed care.
Concurrent Review
Although information about concurrent review was presented by OPP, the
Division of Insurance (www.state.ma.us/doi/ or (617) 521-7794) has jurisdiction over these issues. The insurance carrier must make concurrent review determinations within one working day of receiving all necessary information. In the case of an adverse determination, the carrier must notify the provider by telephone within 24 hours and provide written or electronic notification to the insured within one working day. Service must be continued without liability to the patient until this notification. The notice of adverse determination must contain a substantive clinical justification, and must provide the insured patient with information about the carrier's internal appeals process. When the adverse determination involves inpatient care, the notice must clearly advise the insured of the right to an expedited appeal with the right to a decision prior to discharge. The notice must offer the provider the right to reconsideration of the decision. Reconsideration must be initiated by the physician. A decision must be initiated within one working day of receipt of the request. Reconsideration is not required before an internal appeal.
Internal Grievance Process
Before OPP can conduct an external review, the insured must first go through the carrier's internal appeals process. Written resolution of an internal grievance is required within 30 business days of receipt of the grievance. If medical records are required, the 30 day period begins upon receipt of the signed authorization for release of the information. The carrier must have a process for handling expedited grievances. Cases are eligible for an expedited process if the patient is inpatient or of the physician says the patient would be at risk of substantial harm if treatment is delayed. Expedited grievance decisions must be rendered prior to discharge or within 48 hours for outpatients (see next section for more detail). If the carrier fails to reach a decision within the designated time period, the adverse determination is considered reversed and the health care services must be provided. In the case of inpatient services, coverage must continue at the carrier's expense until the patient is notified of the decision. Adverse determinations are eligible for an external review. If an ongoing service is being terminated, the patient can ask that the external review agency consider whether that service should be continued during the review period.
Expedited Internal Grievance Process
If the insured is inpatient, a resolution must be provided prior to discharge. During the expedited appeal, the disputed coverage must be continued at the carrier's expense. It is important to note that notices of adverse determinations must be received by the insured or the insured's authorized representative prior to discharge. When the insured is hospitalized, simply mailing the notification to the patient's home is not sufficient. Hospital staff may be asked to relay this information to the patient. Also, all notices should contain a clear explanation of the right to proceed to the next expedited appeals level, whether internal or external, as well as the patient's right to request that the services be continued during the external appeals process.
Eligibility for External Review
Members enrolled in a self-insured plan are not eligible for external review by OPP. Self-insured plans are governed by Federal (ERISA) law. Under a self-insured plan, it is the employer, rather than an insurer, who assumes the financial risk for health care coverage. Those covered exclusively by Medicare and MassHealth also are not eligible. Under Medicare, a complaint must be filed with the federal government for denial of services, and patients denied coverage under MassHealth must use the appeals process established by MassHealth. Federal employees covered under FEHBP are also not eligible for an external review. If the grievance involves a service or benefit that has been explicitly excluded from coverage by the carrier, the patient is not eligible for an external review from OPP.
Upon receiving a final adverse determination through the carrier's internal grievance process, a patient has 45 days to file an external review with OPP. A request for an external review must be on a designated external review form. The patient's health plan must provide them with the procedures for requesting an external review and with the external review form whenever a final adverse determination based on medical necessity is issued. However, an application can also be requested from the Department of Public Health or downloaded from the Department's website. The review form must include the signature of the insured or the insured's authorized representative consenting to release of medical information. It must also include a copy of the written final adverse determination issued by the carrier. There is a $25 filing fee, though this may be waived in the case of financial hardship. The remainder of the cost of the review is paid by the health plan.
OPP contracts with three external review agencies to conduct external reviews. External review agents have up to 60 business days to make a determination. The 60 day period begins on the day the external review agent receives the request from the OPP. The review agency may extend the time period for making a decision 15 additional business days. In the event of a serious and immediate threat to the health of the insured, a decision must be rendered within five business days. A case is considered an emergency for purposes of an expedited review if the patient's physician attests that a delay in providing the treatment poses an imminent or serious threat to their health.
The decision of the external review agent is binding.
Managed Care Ombudsman
Stephanie Carter, the Managed Care Ombudsman at the Office of Patient Protection, explained that the role of the ombudsman is to assist members of managed care plans with the processes discussed above. This includes assisting members in accessing their internal grievance and appeal processes offered by their managed care plan in the event of a denial of care, services, or benefits. Ombudsman staff help investigate disputes members may be having with their managed care plan. They provide options and facilitate resolution. They do not order resolution or arbitrate disputes. The ombudsman also provides members with information and explanations of their rights and responsibilities under managed care and about the external review process. The Managed Care Ombudsman program deals with many different issues. Common examples include explaining that not all plans allow a patient to get partial coverage when they go "out of network," or advising how to mount a successful internal appeal. Ms Carter reported that two common areas of disputes are behavioral health and pharmacy coverage.
Handouts from the presentation are available through the CRC. Below are some helpful phone numbers and web-sites:
Office of Patient Protection and Managed Care Ombudsman
617-624-5278, 800-436-7757,
www.mass.gov/dph/opp
Patient Protection Law - Chapter 141 of the Acts of 2000
www.state.ma.us/legis/laws/seslaw00/sl000141.htm
External Review process overview, definitions, eligibility
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