A Healthy Blog

Massachusetts health care — wonky, with a healthy dose of reality

Consumer Appeal Rights Comments Wanted

Consumer Appeal Rights Comments Wanted

July 24, 2013

The Health Policy Commission’s (HPC) Quality Improvement and Patient Protection Committee convened yesterday. The meeting focused on a discussion of the Office of Patient Protection’s (OPP) internal and external review procedures, and culminated in a lively listening session advising OPP on how to make these processes more accessible to patients and consumers.

Jenifer Bosco, director of OPP, presented a comprehensive overview of OPP’s roles and responsibilities, and then focused on OPP’s jurisdiction over the internal and external review processes for fully-insured health plans in the state. (The appeals processes for self-insured plans are governed by federal law and therefore outside of OPP’s jurisdiction).

Carriers are required to submit annual reports to OPP detailing grievances filed by beneficiaries.  The data collected so far for calendar year 2012 shows that over 12,780 decisions were appealed internally to carriers in Massachusetts, with 45% of these claims resolved in favor of the patient. External reviews administered by OPP amounted to a much smaller figure, around 287, with just over a third resolved in favor of the patient.  Given the number of internal appeal denials and the low number of external appeals filed, it seems that patients may not fully understand their rights to an external appeal. HPC Executive Director, David Seltz, noted the importance of increasing awareness of external review rights, and highlighted the role that community organizations can play in this process.

Several positive changes to the review processes will be forthcoming through ACA implementation. This includes a shortening of the external review process from 60 days to 45; reimbursement of a patient’s $25 external review fee if the carrier’s denial is overturned; and enactment of a $75 limit on external review fees per year, regardless of how many decisions a patient appeals. Additionally, under the ACA, an expedited external and internal review can now be filed concurrently, whereas previously an expedited external review could only be requested after an internal appeal was denied.

Mental health and substance use disorder treatment claims are the single largest category of external reviews filed with OPP, a fact reflected in the comments provided during the listening session.  OPP heard from David Matteodo of the Massachusetts Association of Behavioral Health Plans, Clare McGorrian of Health Law Advocates, Elena Eisman of the Massachusetts Psychological Association, and Susan Fendell of the Mental Health Legal Advisors Committee, who all offered valuable input regarding improvement of the review procedures for patients.  Recommendations included strengthening the certification criteria for reviewers; improving clarity and transparency for carrier notices; increasing protections to ensure continuity of care; making the process more accessible for non-English speakers; and simplifying the process so that more patients can navigate it on their own.

OPP is accepting written comments addressing the internal and external review process until July 31, 2013. For details on how to submit comments, see the listening session notice.
 -Claudia Kraft