Independent Medical Review Experiences in California, Phase I and II


 

Publication Date: April 2003

Publisher: California HealthCare Foundation

Author(s): Institute for Medical Quality

Research Area: Health

Type: Report

Coverage: California

Abstract:

What happens when a patient disagrees with a health plan's decision not to authorize care or coverage? Most health plans have long maintained internal review processes, through which they provide an avenue for members to appeal these decisions. A 1998 California law mandated consumer access to an independent, external medical review when treatment was denied for experimental and investigational treatments. The legislation was motivated, in part, by public concern that HMOs might be approving or denying treatment on the basis of cost rather than medical appropriateness. As of January 2001, the definition of cases eligible for independent review was expanded to include all those cases that the plan denied as "not medically necessary." The Institute for Medical Quality conducted a two-part study to determine how the mandated external review process affected consumers and plans in California and to offer recommendations as to how the process might be improved. The study reviewed program outcomes to date and gathered opinions and suggestions for improvement from consumers, health plans, and review organizations. Phase I of the study looks at how the independent medical review process affected the patients, health plans, physicians, and the independent review organazations that engaged in it from January 1999 through December 2000. Phase II reviews the processes and outcomes for those cases introduced after January 2001 under the expanded definition of "medical necessity."