California’s independent medical review (IMR) process was designed to be free of health plan influence, but patients and physicians are often unaware of its built-in safeguards and protections, according to a new study conducted by the Institute for Medical Quality (IMQ) for the California HealthCare Foundation (CHCF).

More than 1,700 California patients have taken advantage of the 1999 law which entitles patients to an external, independent review by medical experts after they have exhausted a health plan’s internal grievance process, or if 30 days have passed since the denial. Patients denied treatments for investigational or experimental reasons are not required to go through internal review. According to DMHC statistics, 36% of health plan denials were overturned in 2001 and 2002.

“Two-thirds of patients did not know that medical experts had no significant financial interest in the patient’s health plan and that findings had to be supported by medical and scientific evidence,” said Jill Silverman, MSPH, president and CEO of IMQ. “Seventy percent of physicians did not know if the health plan played a role in selecting the medical experts for the IMR.”

“Only about half of respondents felt confident or very confident that consideration was given to their individual medical status, that the review was impartial, that consideration was given to all available scientific information and that individual reviewers had appropriate expertise,” Silverman said.

When requested by a patient, the external review of a health plan treatment denial is conducted by an independent review organization that contracts with the Department of Managed Health Care, which has managed the program for consumers since 2001.

The study, Independent Medical Review Experiences in California, Phase II: Cases Including Medical Necessity, reviewed the experiences of patients, physicians and health plans with IMR during 2001 and identified several ways in which the external review process might be improved.

Patients, health plans and physician respondents all felt that the external review process should be more open to patients and physicians and that more should be known about reviewers’ qualifications. The report recommends:

• Notifying patients of what information is sent to the independent review organization (IRO).
• Requiring the IRO to contact the patient to verify that the correct records are being reviewed.
• Advising the patient of the reviewer’s specialty before the review begins.
• Considering more than one expert on a panel so that different views are represented.
• Giving the patient’s physician access to the reviewer to discuss the case.

  Based on written surveys and follow-up interviews, nearly three-quarters of patients believed they had a 50/50 chance of having their health plan denial overturned. In fact, during the 2001 study period 37% of all health plan denials were overturned. Physicians did not share their patients’ optimism: only 33% of physicians thought chances were good that a patient’s denial would be overturned.

  An unexpected finding from follow-up telephone conversations was a perception among a number of surveyed patients regarding personal difficulties receiving an IMR-approved service or having it paid for by their health plan. All but one of the health plans report they have a process in place to verify that IMR decisions are implemented, as does the DMHC. Once learning of these results, the DMHC initiated its own inquiry to determine if a service or treatment had in fact been provided or paid as required.

  All the health plans, except one, reported that results of recent IMR cases had influenced internal medical policy and coverage decisions, particularly related to Bariatric (gastric bypass) surgery, drug criteria, breast surgery, chiropractic and physical therapy treatments, and oral maxillofacial procedures.

  In other findings:

• Patients may be staying in the health plan grievance process longer than necessary. Only half of surveyed patients reported completing the health plan process within the 30-day limit.
• The relatively low number of IMR cases – less than 1% of managed health care members – may be due to the difficulty of the path to IMR that goes through the health plan’s denial process. In five health plans where data was available, only 3 to 25% of cases potentially eligible for IMR were filed.
• Two-thirds of patients were not aware of IMR as an option before their direct involvement and three-fourths of their physicians were unaware of the process until it was actually needed.
• The seven health plans (representing 94% of California IMRs completed in 2001) in the study were cited by patients as the most frequent source of knowledge about IMR, but not all of these plans reported including IMR information in all places required by law.
• Sixty percent of patients were satisfied with the amount of time it took to receive the results of the IMR and a slightly higher percentage realized that the DMHC was involved in the process.
• Patients with investigational/experimental treatment decisions were less confident in the IMR process than patients who had cases related to “medical necessity.”
• Following the IMR, a patient’s confidence that their health plan covered medically necessary services depended on whether their denial was overturned or upheld. Sixty-three percent of those with denials overturned by IMR said the process increased confidence, while 89% of those whose denials were upheld said that their confidence had decreased.
  The report includes additional recommendations for improving the quality of IMR and making it more accessible and efficient for consumers, physicians, and health plans. These include:

• Formalize steps leading up to IMR and advising patients at the beginning of the grievance process that they may apply for IMR if the case is unresolved after 30 days.
• Focus IMR notification and instructions in denial letters and give simple clear steps that patients can take after receiving a denial.
• Assist patients in submitting information to the review, especially those with investigational/experimental cases, and in locating information to support their case.
• Provide patients with information that helps them clearly understand reasons for the IRO decision.
• Provide follow-up support for patients by verifying that the decision was implemented.
• Develop effective ways to inform physicians of the availability of IMR.
• Offer health plans information to understand the criteria and literature used to make IRO decisions.
• Provide patients with a simple “How To” guide outlining appeal and IMR steps.
• Provide adequate feedback to and monitoring of IROs to ensure a quality process.

  Utilizing a written survey and telephone interviews, the Phase II study reviewed the experiences of 610 patients whose cases went through IMR in California during 2001. For additional information on survey methodology and for background on the history of IMR law, please see the report.

  About IMQ The Institute for Medical Quality (IMQ) is a 501(c)(6) nonprofit organization dedicated to improving the quality of care provided to patients across the continuum of health care. IMQ offers a wide range of educational, accreditation, consultation, and certification programs.