California's independent medical review provides consumers a way to appeal health coverage denials. What lessons have been learned, and is change needed?
For more than a decade, California has required state-regulated health plans to provide consumers with the opportunity for an independent external review of coverage denials through its independent medical review (IMR) program. This important program offers individuals a way to get a second opinion on care that has been denied or delayed by their plans.
The federal Affordable Care Act (ACA) mandates independent medical review for all coverage, including not only state-regulated health insurance products but also self-insured group plans subject primarily to federal oversight. The federal government has determined that California's IMR program meets the ACA standards.
The expansion of external review under health reform, and the accumulation of more than 10 years of IMR cases in California, provide a timely opportunity to examine the California experience for lessons learned and potential improvements. This review of California's IMR program uses data from both the California Department of Insurance (CDI) and the California Department of Managed Health Care (DMHC) for all IMR cases from the program's inception through 2010.
Key findings include:
- Nearly 12,000 Californians obtained an IMR between 2001 and 2010, with the annual number of IMR cases tripling during this time.
- More than half of IMR cases involved orthopedics, neurology, mental health, or cancer.
- In 46% of IMR cases in 2010, the independent reviewers overturned the original decision and required the health plan to provide coverage.
- IMR cases clustered around situations where the medical knowledge was evolving. Medical consensus correlated with fewer IMRs; lack of medical consensus meant more IMRs.
- Independent reviewers have not always met California IMR standards. Decisions have not been uniformly documented, and reviewers have not always been appropriately credentialed.
The complete report is available under Document Downloads. This report was updated on January 31, 2012, to incorporate additional information about the data analyzed for the report.