Many California Patients, Physicians Unaware of HMO Independent Review Program

Many managed care patients and physicians in California are unaware of the state program that allows patients to appeal the decisions of their health plans, according to a report issued last week by the California HealthCare Foundation, the Los Angeles Times reports (Costello, Los Angeles Times, 5/5). Under California law, managed care patients have the right to an independent medical 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, 7/2/02). Patients must first file complaints with their health plans; in the event that patients cannot resolve their complaints, they can request help from the state Department of Managed Health Care. An independent review board of physicians not associated with the health plan contracts with the state DMHC to review the cases. Many experts predicted that a large number of the state's 18 million managed care patients who disagreed with their health plans over denials of care would file an appeal through the independent review program; however, the state DMHC has received only 1,700 requests for review since the program took effect in 2001.

The report -- compiled from interviews with 154 of the 610 California managed care patients who requested an independent review in 2001 -- found that two-thirds of patients and 75% of physicians were unaware of the independent review program prior to their participation; seven health plans, which represented 94% of the independent review requests, participated in the report. The report also found that many patients who participated in the independent review program "believe it is skewed in favor of their health plans," the Times reports. The independent review board ruled in favor of the patient in 36% of the cases, the report found. The report recommended that the state DMHC develop a "how to" guide about the independent review program and distribute the guide in physician offices and employer human resource departments to increase participation. The report also recommended a campaign to explain the program to physicians and establish a system to ensure that health plans implement the decisions of the independent review board "in a timely manner," the Times reports.

"Many consumers still don't understand that the program is objective and free from health plan influence," Margaret Laws, director of policy and planning at CHCF, said. Steven Fisher, deputy director of the state DMHC, added, "It's been a slow start. We need to do a better job of getting the message out and letting patients know that they now are in the driver's seat if they have a problem" with their health plans. However, some consumer advocacy groups said that "many patients never pursue their complaints past the health plan's internal review because the process can be cumbersome, confusing and frustrating," the Times reports. "The internal reviews are complicated and exhausting. Unless someone has help sorting through the process, the insurer has the upper hand. It's all the worse for the poorest patients and non-English-speaking patients, who often get overwhelmed," Kevin Simpson, executive director of the Health Assistance Partnership, an advocacy group, said (Los Angeles Times, 5/5).