By Marcia Lammando, RN
A key role of a medical director is to evaluate recommended treatments or services and decide if they are going to be covered by insurance. Medical directors seek assistance from physicians they know who have specialized training before making a decision. This informal process is now moving into the 21st century and is spurring on the independent medical review movement.
Pennsylvania, along with 40 other states and the District of Columbia, recognizes use of an independent medical review as a means to appeal health plan coverage decisions after all of the health plan’s appeals mechanisms are exhausted. Physicians and patients are generally unaware that this option is available once the health plan has made a final decision on the medical necessity or appropriateness of a recommended treatment.
All independent medical reviews are not created equally. A prototype independent medical review is the process through which a qualified physician or health care professional, independent of all affected parties, reviews a patient’s case. For example, a difference of opinion about the medical necessity and/or appropriateness of recommended care and services can arise between the patient and the medical director at the health plan. Health plans are required by law to provide independent medical review options to physicians and patients when internal appeals and grievance processes have not provided the expected level of satisfaction to the patient’s request for care and services. Physicians providing an independent medical review make an independent, unbiased decision about an individual’s health care.
Independent review stands as a means for the health care community to become involved with the evaluation of medical decisions made by health plan medical directors. Most state laws enacted to protect the rights of patients require health benefit plans to abide by the independent reviewers’ determination. If the independent reviewer disagrees with the determination by the health plan, the plan must pay for the treatment in question, even if the health plan appeals to a higher court. “Medical judgement will not be so readily overridden by the HMOs,” said Leonard Nelson of the AMA/State Medical Societies Litigation Center after a recent Supreme Court decision upholding an Illinois law that established an independent medical review system.
Independent review organizations (IRO) are entities that provide independent review services to government agencies and health plans. IROs must comply with stringent standards that outline the systems that must be in place in order to conduct independent medical reviews. These standards seek to assure that all accredited IROs are providing services in a consistent manner, thereby attempting to decrease variation in the process of medical decision making.
Unfortunately, due to the variation inherent in those states which have enacted independent review laws, issues still remain that need to be resolved with the independent review processes. A recent study of the independent review process in 39 states and the District of Columbia, conducted by the American Association of Health Plans (AAHP), found that “independent review organizations are poised to influence quality of health care significantly in the coming years, by reassuring consumers that their health plans are accountable and by spotlighting best medical evidence.” The adoption of national review standards would be of great assistance in decreasing variation in the decision making process throughout the country.
An IRO, when a case is referred, must assign the case to a physician or health care professional who is practicing within the same specialty as the physician or health care professional who recommended the care initially. Prior to assignment of the case, the IRO must ensure that the physician or health care professional is fully credentialed, maintains board certification in his/her specialty, and is familiar with the treatment initially prescribed. Additionally, the IRO must provide the independent reviewer with appropriate clinical practice guidelines that are evidence-based or that have been developed by a peer review or consensus process. This ensures that the reviewer has the most up-to-date information with which to consider making a health care determination.
Based not only on industry standards, but also on state law in some instances, the independent review process is required to be completed within prescribed time frames. In some states, the review process is mandated to be completed in 24 hours regardless of the impact of the disputed care on the patient’s well being. This time frame is very restrictive, given that it does not allow for reviewers to collect the necessary information that could be helpful in the decision-making process.
The typical review is generally completed within a six to ten day time frame. The IRO must provide, according to industry standard, the reviewer’s determination to the referring entity within two days after a decision is rendered. In the case where a patient’s condition may be life-threatening, the case deliberation and decision process can take no longer than 72 hours and the determination must be provided immediately to the referring entity.
Physicians play a vital role in independent review. Those physicians who participate in the independent review process indicate a very high degree of satisfaction with the work. For a physician, independent review provides an opportunity to have an impact on the health care of not only their patients, but also on the health care of the community at large. “Independent medical review is steadily emerging as a crucial component of the health care framework, with the potential to give patients both the peace of mind that comes with increased accountability, and the assurance that their care is keeping pace with science,” said AAHP President and CEO Karen Ignagni.
Physicians and other health care professionals should expect to be reimbursed for their services when performing independent reviews. Additionally, it is anticipated the prospective reviewer will be currently practicing in his/her specialty, and possess the latest knowledge of up-to-date treatment practices within that specialty.
Marcia Lammando, RN, BSN, MHSA, is Director of Clinical Consulting for PMSCO Healthcare Consulting, a subsidiary of the Pennsylvania Medical Society.