Appeals Handled by The Office of the Healthcare Advocate UConn Health Disparities Institute Sept. 7, 2018 Appeals Handled by The Office of the Healthcare Advocate Ted Doolittle – State Healthcare Advocate

What is OHA? Independent state agency Free assistance to any consumer with questions about health insurance or plan selection Represent consumers in insurance denials Speak for health insurance consumer on policy with government, industry and other stakeholders

Assist and educate consumers when selecting a health plan Explain insurance plans, benefits, cost-sharing to consumers to assist with plan selection and maximize utilization Educate consumers on their health insurance rights and how to advocate on their own behalf Answer questions and assist consumers in appealing a health plan’s denial of a benefit or service.

Help consumers resolve problems with their health insurance plans Any CT resident who requests our help with a health related issue or anyone with a policy written in CT Fully or self insured Public or private Exchange or non-Exchange Case Management (assess, coordinate, monitor and evaluate options and services required to meet an individual’s health or advocacy needs)

Consumer calls or complaints. 2017: 6,023 Consumer calls or complaints.

2017: $10.2 million Consumer savings

Savings per consumer call. 2017: $1,694 Savings per consumer call.

OHA continues to provide consumers with much- needed education and assistance on appeals, peer to peer review, pre-authorization and concurrent reviews.

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Mental health largest category

OHA lacks reliable data due to data entry idiosyncracies Appeal Type OHA lacks reliable data due to data entry idiosyncracies Observationally, vast majority of our appeals are medical necessity Carrier’s medical experts disagree with treating provider Experimental & unproven

Other identifiable categories: Appeal Type, ctd. Other identifiable categories: Out-of-network disputes Eligibility & enrollment (i.e., disputes over whether coverage exists; e.g., premium payment disputes, COBRA issues) Plan benefits disputes (i.e., covered vs. non-covered; preventative vs. diagnostic) Billing/coding disputes

Medical Necessity Appeals OHA must obtain & review medical records Utilize OHA in-house clinical expertise or treating provider expertise Medical literature research Write appeal letters Follow appeal levels within carrier, then external review Estimated ultimate success rate well over 50% But estimated 1st level (internal) success rate much lower

Medical Necessity Appeals Solutions Hypothesis: consumers who do not seek expert assistance much less likely to appeal and/or prevail Carrier internal review process is not catching many cases that will ultimately be overturned Internal reviews ineffective Causes: high caseloads; quick turnarounds; 1st level reviewers do not have the benefit of systematic gathering of medical records, clinical evidence, and marshalling the story Could be causing consumers to abandon valid appeals Should carriers be re-directing resources to more/faster external review?

Medical Necessity Appeals Solutions Hypothesis: Many legitimate medical necessity claims are not pursued Large scale medical claims litigation model: Review many claims; then extrapolate the result Could this model be used by large insurance plans Annually randomly pull and review statistically significant sample of unappealed denials Determine incorrect denial rate Use money to reduce premium next year Logistical barriers; expense; gathering/reviewing medical records labor intensive

Medical Necessity Appeals Solutions Analogous medical claims review & extrapolation effort: CMS’s Probable Fraud Measurement Pilot Effort to review nationwide Medicare Home Health claims to determine probable fraud rate in the sector Intensive design & preliminary work by CMS’s Center for Program Integrity Cost estimates were several million dollars Seems to have been lost in transition to new administration

Medical Necessity Appeals Solutions Industry should fund programs like OHA offering free expert appeal assistance in more states Medical necessity denials should be presumptively appealed or automatically reviewed by another level Internal carrier 1st level appeal processes could be audited/reviewed for effectiveness Rotate medical professionals responsible for internal peer review, just as businesses must rotate auditors periodically

Questions? 860-331-2441 Healthcare.Advocate@ct.gov