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Few People Aware of Medical Review Program

It has been 11 years since California launched its Independent Medical Review program, an appeals process that allows Californians to challenge denial or delay of coverage by private health care insurers.

In the Capitol Building in Sacramento yesterday, a policy briefing laid out the findings of a new report on IMR that includes praise for its effectiveness and some recommendations on how to make the program stronger.

The briefing was sponsored by the California HealthCare Foundation, which commissioned the report and publishes California Healthline.

One of the biggest hurdles to improvement, according to the report, is that not many people in the state even know the program exists. That was a particular concern to panelist Beth Capell of Health Access California.

“The very low rate of utilization is troublesome,” Capell said. Many could benefit but “there is only a fraction of the people in California who take advantage of it,” Capell said.

It’s not just patients who need to be informed about the program, according to Carol Lee of the California Medical Association Foundation. “We need to explore the lack of awareness,” Lee said. “I think we’d be stunned at how many physicians don’t know this exists. And we think a lot of patients won’t take advantage of this unless their physician says something.”

According to Lyn Gage, a health program manager for the Department of Managed Health Care (which, along with the state Department of Insurance, runs the IMR program), her department has made a variety of outreach efforts.

“Awareness of the IMR program is really critical for us,” Gage said. “We require health plans to make sure people know about IMR, and we work with the Office of the Patient Advocate and with community-based organizations to make sure people know about it.” A consumer call center has been set up, she said, to answer Californians’ questions about how to file a challenge.

Last year, Gage said, the department handled 1,770 requests for an IMR. Some of those were reversed by the health plan, and some were decided in favor of patients by an independent reviewer (approximately 46% of cases, according to the report). “We believe that the plans would not have reversed those denials if we were not involved,” she said. “So, in total, about 61% of the cases sent to IMR were overturned in the consumer’s favor.”

Tony Cignarale of the California Department of Insurance said that some insurance companies are denying coverage, but not necessarily basing those denials on medical necessity — but instead categorizing the denial as a lack of coverage.

“Complex coverage disputes have become a major issue in the last year,” Cignarale said. “Insurance companies may deny for other reasons, but might call it a coverage issue. So we have to decide, is this a coverage issue, or should it go to IMR? Because maybe they don’t want it to go to IMR.”

According to Patrick Johnston of the California Association of Health Plans, many challenges are over coverage issues. So the state needs to be careful in deciding cases on what it believes should be covered.

“Coverage matters,” Johnston said. “If you’re not thinking about coverage, then you’re not thinking about cost.”

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