California Department of Managed Health Care

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• California Department of Managed Health Care
• Tom Gilevich
• Independent Medical Review (in Health Care
  Delivery Systems)
• May 2, 2003
• Los Angeles, California

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• Independent Medical Review - IMR
• (External review)
• An informal resolution of selected disputes over
  health care services from an HMO, health insurer
  or other third-party payer
• Impartial and independent
• Dispute-specific assessment
• The last informal process available

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Treatment Authorization Process Initial
DenialInternal Grievance AppealAfter the
plan has its shot .. Complaints to Dept. of
Managed Health Care www.hmohelp.ca.gov HMO
Helpline (888) HMO-2219
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• Purpose of IMR
• Restoring confidence in managed care
• Consumer demand for safeguards
• Public policy accommodation
• Industry acceptance
• 42 states Medicare TRICARE

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• California IMR system (Contd)
• Written determinations by reviewers provided
• to all parties
• Adopted by DMHC and binding on plan
• Civil action against plan requires exhaustion
  of IMR process

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California IMR systemThree types of disputes
are eligible - Experimental denials -
Medical necessity denials - Denied
reimbursement for emergency/urgent
servicesNot coverage issues plan
determinations based on a finding the disputed
services are not medically necessary.
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• California IMR system (Contd)
• Completed internal grievance system
• One page application no cost to applicant
• No threshold for amount in dispute
• Department determines eligibility
• State contracts with review organizations
• Health plan provides information
• Qualification conflict screening of reviewers

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• Distinctions among IMR systems
• When is it available what does it decide
• Automatic or application
• Control, payment and administration
• Reviewer selection
• Standards evidence used
• How does it work due process
• Review and monitoring or reviews
• Consequences if not utilized

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