Los Angeles Times Examines State’s External Review Process

The Los Angeles Times yesterday examined external review boards, which California and 40 other states have established to investigate denials of care by health plans and "give people a fighting chance in disputes" (Rosenblatt, Los Angeles Times, 9/30). Under California law, managed care patients have the right to an external review in disputes with their health plans over treatment denials. Health plans cover the cost of the reviews, which can range from $395 to $25,000 (California Healthline, 7/2). The state external review process, established in January 2000, provides patients with "another way to press their case," in addition to the internal appeals process at health plans, and places "pressure" on plans to settle complaints before they "get the attention of state regulators," the Times reports. Most health plans have a two-step appeals process: after plans deny treatment, they will reconsider the decision "once, then again." After the third denial of care, patients can request help from the Department of Managed Health Care, which receives about 15,000 telephone calls each month. The department sends the "most difficult" cases to an external review board, a "medical Supreme Court" that includes private doctors hired by the state. Over the past three years, the state external review board has addressed 924 cases, and patients have won about one-third of the time. However, DMHC Director Daniel Zingale said that many patients "don't realize they have appeal rights," adding, "The health care system is so overwhelming, confusing and complex" (Los Angeles Times, 9/30). In response, the DMHC has sent letters to 100 medical groups, 250 consumer organizations, 75 medical and health associations, 55 treatment facilities and a number of lawmakers statewide to help inform residents about the independent review system. The department also has a help center and a Web site that provide information about the system (California Healthline, 7/2).