|
ANALYSIS OF HOUSE BILL 2865 Resolving grievances against health carriers.
|
|
Health Care Committee 27 January 1998 Washington State House of Representatives |
SPONSORS: Representatives Dyer and Skinner.
PURPOSE: To establish two levels of health carrier grievance procedures [GP] and a pilot proram for external review of medical necessity claims under the public employees benefit plan.
BACKGROUND: The meaning of Amanaged care@ varies among private and public purchasers, patients, carriers, and regulators. Although the term is referenced in no less than sixteen sections of state law, a statutory definition is lacking. The Insurance Commissioner defines a "managed care plan," in recently adopted rules, as a A. . . plan that coordinates the provision of covered health care services to a covered person through the use of a primary care provider and a network.@ [WAC 284-43-130: effective 2/ 22/98]. In a recently held legislative training session on managed care, the term was defined as Aapproaches to health services delivery and benefit design that integrate management and coordination of services with financing to influence utilization, cost, quality, and outcomes.@
Although pedants date managed care organizations (MCO=s), e.g., health maintenance organizations (HMO=s), back to the late 1920's, the real growth in managed care occurred over the past two decades; while MCO=s had around six million enrollees in 1976, it is estimated that over 100 million Americans are enrolled in some form of managed care today.
In recent years, increasing pressure has been placed on MCO=s from private and public purchasers to control costs, which has met with a corresponding pressure from enrollees and providers to assure quality and choice. The confluence of these vectors has resulted in a land-office business of quality assurance activities. The National Committee on Quality Assurance (NCQA), the Utilization Review Accreditation Committee (URAC), the National Association of Insurance Commissioners (NAIC), and other organizations have been rapidly developing standards to accredit MCO=s based on quality measures. An explicit grievance procedure standard has been identified as a key component of a quality assurance program.
The medical necessity of a service, stay, or procedure is sometime contentious. Presently this issue is not addressed statutorily and is usually handled through a carrier=s grievance procedures. Some consumer advocates have proposed an external review process for medical necessity review.
CURRENT LAW: There are five statutory references to enrollee grievances:
RCW 48.02.160 gives the Insurance Commissioner the Aspecial duty@ of AProviding assistance to . . . the public in obtaining information about insurance products and in resolving complaints. . . .@
RCW 48.46.100 (repealed in HB 2865) requires each health maintenance organization (to) establish @. . . a grievance procedure. . . to provide reasonable and effective resolution of complaints initiated by enrolled participants. . . .@
RCW 48.43.005(13) defines "Grievance" (see below).
RCW 48.43.095 requires carriers to provide enrollees, upon request with AA copy of all grievance procedures for claim or service denial and for dissatisfaction with care. . . .@
RCW 48.43.055 (amended in HB 2865) requires each carrier (to) Afile with the commissioner its procedures for review and adjudication of complaints initiated by covered persons or health care providers.@
The Insurance Commissioner has not promulgated rules on grievance procedures.
SUMMARY:
Grievance defined
A written complaint submitted by or on behalf of a covered person regarding: (a) Denial of payment for medical services or nonprovision of medical services included in the covered person's health benefit plan, or (b) service delivery issues other than denial of payment for medical services or nonprovision of medical services, including dissatisfaction with medical care, waiting time for medical services, provider or staff attitude or demeanor, or dissatisfaction with service provided by the health carrier.@ [RCW 48.43.005(13)]
Utilization Review
The grievance procedure (GP) does not apply to a reconsideration of a utilization review[1] resolved within 5 business days of the utilization review decision, however, if a covered person remains dissatisfied, a grievance may submitted.
Requirements of a covered person filing a grievance.
To submit a grievance in any form, but include written authorization if wishing a representative.
Participate in grievance progress
If unsatisfied with first level decision, file for second level grievance within 90 days of receipt of first level decision.
If unsatisfied with second level grievance decision, submit, if desired, the grievance to nonbinding mediation.
Requirements of the health carrier.
Establish a written procedure for receiving and resolving grievances.
At each level of review, include staff with sufficient background and authority to address grievance.
Make available the carrier=s medical director in the review of any grievance involving a clinical issues.
Provide toll free or collect telephone access for persons unable to present a written grievance because of limited English proficiency, literacy problems, or disability.
Provide reasonable assistance at all stages of the grievance process to covered persons with difficulties in participating.
Issue written decisions that include: A statement of the carrier's understanding of the grievance; the decision in plain language explaining the grievance determination and references to relevant policies, procedures, and contract terms; and (after second level) notice of the insurance commissioner's toll-free number and address.
First Level Grievance
Within 3 business days of receiving a grievance, the carrier must acknowledge, its receipt in writing.
The process shall not exceed 30 days from receipt of grievance, but, if external information needs to be collected, the carrier may take an additional 14 days. Also, the period may be extended upon mutual agreement.
Second Level Grievance
If dissatisfied with the first level decision, the covered persons must submit a written request for review within 90 days of receipt of first level decision.
The covered person is given an opportunity to appear in person before the representative of the carrier.
The grievance must be processed within 30 days, but can be extended for a specified period if mutually agreed.
A review panel must be created comprising of representatives of the health carrier not otherwise participating in the first level review.
If unsatisfied with the second level decision, the covered person may submit the grievance to nonbinding mediation.
Expedited Review of a Grievance
This review is limited to cases when denial may seriously jeopardize the life or ultimate health care outcome of a covered person.
Carrier must appoint an appropriate health care provider to participate in expedited reviews and provide reasonable access to specialty providers who typically manage the issue under review.
All necessary information must be transmitted between the health carrier and covered person in the most expeditious method.
Carrier must make a decision and notify the covered person as expeditiously as the medical condition of the covered person requires, but no more than two business days or 72 hours.
Where the expedited review process does not resolve the grievance, the covered person may request a second level grievance review.
Filings with the Insurance Commissioner
Each health carriermust submit an annual report to the Commissioner, no later than March 31st which includes grievance information summarized in the following three categories: (1) Managed medical assistance plans-- commonly known as "healthy options"; (2) closed network plans; and (3) point of service/other. The report is to include: Numbers of each type of grievance and percentage closed at each level, lengths of time between filing of grievance and closure, nature of the grievances, access problems, and types of denials.
External Review Pilot Program
The administrator of the Health Care Authority (HCA) is authorized to provide contractual incentives to insuring entities, including the HCA=s self-funded medical plans, who agree to participate in a voluntary two-year pilot program for independent external review of medical necessity grievances. The costs and benefits of external review and other processes for resolution of medical necessity grievances shall be studied by the Health Care Policy Technical Advisory Committee created in RCW 41.05.150. The study shall analyze existing processes, and any external review pilot programs nitiated pursuant to this bill. An interim report shall be completed no later than September 1, 1999, and a final report no later than six months after completion of the pilot program outlined in this bill.