Filig A Appeal Based O a Parity Violatio K E N N E DY F O R U M I S S U E B R I E F ( J U N E 2 0 1 7 )
Cotets Itroductio...1 A Family Health Crisis...3 Promotig Metal Health Parity...3 Appeals Overview...4 Parity Violatio Explaied...7 Filig a Parity Appeal...10 Call to Actio: Te Steps...11 Fial Thoughts...15 About The Keedy Forum...16 Published by The Keedy Forum 2017 Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio Itroductio The Uited States is respected aroud the world as a leader i the developmet of medical breakthroughs i life-savig drugs ad vaccies, surgical procedures such as trasplats, cuttig-edge medical equipmet, diagostics ad molecular medicie. These advacemets, amog others, have trasformed the global health care system. However, the U.S. does ot garer the same respect for its health isurace system. Despite this, some elemets of how the U.S. offers isurace coverage, icludig welless ad populatio health techiques, are studied iteratioally. May U.S. developed itervetios ad iovatios have optimized cliical outcomes where the health care dollar is ofte limited. Despite medical advaces, a primary area of frustratio for may Americas erolled i private or public sposored health isurace arragemets is how isurers make coverage determiatios for medical ad pharmaceutical care. Ofte, coverage is deied usig esoteric terms such as the care is ot medically ecessary or the care is cosidered experimetal or ivestigatioal. What makes the situatio eve worse is the complex ad fragmeted appeals system that Americas ad their attedig providers must use whe askig a isurer, payer, or other etity, to recosider the deial or adverse determiatio. Patiets, their families ad caregivers are ofte ot aware of their appeal rights or kowledgeable about other due process protectios afforded them by law. Idividuals with behavioral health coditios are ofte some of the most vulerable ad, their health is closely depedet upo how ad whe health plas decide to cover their care. Historically, metal health ad substace use disorder treatmets were subject to more restrictive limits tha medical ad surgical services, resultig i frequet care deials ad other adverse determiatios. Prior to 2008, these uequal medical maagemet practices were legal i may states. Thus, idividuals typically could ot use the appeals process to questio ufair ad harmful decisios based o iequities betwee how a isurer was coverig medical/surgical care versus behavioral health care. However, uder the Federal Parity Law, health isurers must treat behavioral health beefits the same as physical health beefits, givig ew ad icreased protectios to cosumers accessig care. It is time to rethik ad improve o the existig health isurace appeal system with a eye towards makig the appeals process more efficiet, trasparet ad meaigful. This issue brief describes differet types of potetial parity violatios to illustrate oe s right to file a appeal based o how health plas treat physical health services differetly tha metal health ad substace use disorder (behavioral health) treatmets. The aalysis focuses o how protectios fouded withi the Federal Parity Law ca be used as a vehicle to icrease access to the appeals process. The Keedy Forum www.thekeedyforum.org 1
Filig A Appeal Based O a Parity Violatio I additio, this policy paper provides a cocise overview of how the appeal system works (or does ot work) for idividuals with behavioral health coditios. The appeals process, especially for parity violatios, remais a complex ad cofusig system for stakeholders. It is time to rethik ad improve o the existig health isurace appeal system with a eye towards makig the appeals process more efficiet, trasparet ad meaigful. A robust appeal system also will create a deterret effect if those who iappropriately dey care are held accoutable. The Keedy Forum recommeds 10 actio steps to help improve the health isurace appeal system: 1. Icrease awareess of the appeal process 2. Promote more due process ad trasparecy 3. Allow attedig providers ad other advocates to file appeals 4. Simplify the appeals process 5. Stadardize the appeal system across market segmets ad state lies 6. Upgrade the exteral review process 7. File more appeals 8. Leverage techology to improve efficiecy 9. Update oversight regulatios 10. Promote advocacy ad educatio programs. While this report focuses o behavioral health disorders, these recommedatios apply to all types of health isurace appeals, ad would beefit everyoe who is seekig a recosideratio for care that has bee deied by a health pla. 2 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio A Family Health Crisis O her 18th birthday, a youg woma attempted suicide after strugglig with depressio, axiety, ad several substace use disorders. Thakfully, her attempt was usuccessful ad her family foud appropriate care at two residetial treatmet facilities. Over the course of a year, she addressed the uderlyig issues associated with both her metal health issues ad history of addictio. Her treatmet, which cost the family over $75,000, was ot covered by the family s health isurace coverage. Today, she is a successful youg professioal who cotiues to use the copig mechaisms leared i treatmet. The youg woma s parets were so overwhelmed with their daughter s situatio ad the complicated appeal system that they ever sought reimbursemet by filig a appeal. All too ofte, i the throes of serious illess, families ad frieds must scramble to fid care for a loved oe i crisis. To add isult to ijury, this care may be ulawfully deied, leavig may patiets grapplig with astroomical health care bills that may affect the etire family for years to come. If this family had ot uderwritte the cost of treatmet, the outcome would likely be much differet; they took out loas ad a secod mortgage to cover life-savig care for their daughter. May Americas do ot have such optios. Promotig Metal Health Parity To level the playig field ad achieve equity for idividuals sufferig from addictio or metal health issues, a coalitio of stakeholders worked together to pass the Paul Wellstoe ad Pete Domeici Metal Health Parity ad Addictio Equity Act of 2008 (The Federal Parity Law). The law ad subsequet regulatios are focused o edig discrimiatory health isurace practices agaist those with behavioral health coditios. As medical expeses cotiue to rise, both private ad public payers such as commercial isurers, employer self-fuded plas, Medicaid, ad state ad local govermetal health plas, ofte rely o medical maagemet practices as a cost cotaimet strategy. This icludes utilizatio maagemet (UM) programs that review ad approve care prior to treatmet (i.e. pre-authorizatio or prospective UM), ogoig treatmet ad services (i.e. cocurret UM), ad reimbursemet of medical claims (i.e. retrospective UM). While both physical ad behavioral health beefits are subject to these practices, may payers cotiue to apply treatmet limitatios to behavioral health services that are more rigorous tha those applied to physical health beefits, ofte to save moey. These restrictios o coverage ca take may forms but largely fall withi three categories: fiacial requiremets, quatitative treatmet limitatios (QTLs), ad o-quatitative treatmet limitatios (NQTLs): The Keedy Forum www.thekeedyforum.org 3
Filig A Appeal Based O a Parity Violatio Fiacial requiremets iclude premiums, deductibles, co-paymets, ad other forms of cost-sharig. Quatitative treatmet limitatios iclude visit ad day limits, also kow as legth of stay limitatios. No-quatitative treatmet limitatios iclude utilizatio maagemet strategies that restrict or dey access to care, such as prior authorizatio requiremets (which ivolve medical ecessity reviews), step therapy or fail-first protocols, ad geographic restrictios. The uequal applicatio of these practices to behavioral health ca costitute a violatio of federal ad state parity laws. The Federal Parity Law prevets health plas from applyig fiacial requiremets or treatmet limitatios (both quatitative ad o-quatitative) to behavioral health beefits that are more restrictive tha those applied to physical health beefits. Further, plas caot apply separate treatmet limitatios oly to behavioral health beefits. Through these requiremets, the law aims to ed the discrimiatory applicatio of iequitable medical maagemet practices. 1 The Federal Parity Law prevets health plas from applyig fiacial requiremets or treatmet limitatios (both quatitative ad o-quatitative) to behavioral health beefits that are more restrictive tha those applied to physical health beefits. Appeals Overview If a patiet or their attedig provider believes that a health pla has wrogfully issued a coverage deial, or has ot covered behavioral health services i the same maer as services offered o the physical health side, they ca usually file a iteral appeal with the health pla. Uder may circumstaces, they may also follow with a exteral appeal. Health pla appeals are subject to federal ad state rules establishig miimum stadards for otice, qualificatios of reviewers, timeframes for decisios, ad other aspects of the process. Although the Federal Parity Law ad the rules goverig health pla appeals do ot establish a distict category of parity appeals, potetial parity violatios may be raised i both iteral ad exteral appeals. (For simplicity s sake, such appeals will be referred to below as parity appeals ). If the patiet or their desigee is still dissatisfied with the outcome of the iteral appeal, i may cases the patiet may the request a exteral review by either a state agecy or a idepedet review orgaizatio (IRO). The patiet may or may ot have access to a exteral appeal depedig o several factors, icludig the ature of the deial or adverse beefit determiatio (where a pla deies or limits coverage or paymet for the requested behavioral or medical treatmet or services), type of isurace, ad where the patiet lives. 4 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio Ofte, whe a deial of care is issued by a health pla, the patiet is uaware of their right to appeal that decisio. Eve though up to 24 percet of all health care claims are deied, may Americas do ot kow where to file a appeal. 2 I fact, a 2015 Cosumers Uio study foud: Two-thirds of privately isured Americas are ucertai about which state etity is resposible for resolvig issues with health isurace billig; Most (87 percet) do ot kow the state agecy/departmet tasked with hadlig health isurace complaits; ad May (72 percet) are usure if they have the right to appeal to the state/a idepedet medical expert if their health pla refuses coverage for medical services they thik they eed. 3 Although the Federal Parity Law ad the rules goverig health pla appeals do ot establish a distict category of parity appeals, potetial parity violatios may be raised i both iteral ad exteral appeals. The first step i appealig a deial of care, or aother adverse determiatio related to health isurace coverage, is to file a iteral appeal with the health pla. I may cases, the iteral appeals process must be exhausted before the perso filig the appeal is eligible to move to a exteral review. Typically, two etry poits are available to iitiate a appeal: Medical Necessity or Cliical Appeal: The first etry poit is to file a cliical or medical ecessity appeal. A isured idividual, family member or attedig or desigated provider will file this type of appeal whe the health pla has deied or reduced the level of care based o what the pla deems is medically ecessary. This decisio is based upo evidece-based medical ecessity criteria or guidelies that must be fully accessible to the iterested parties. Uder federal ad state law, health plas are required to provide a writte explaatio for medical ecessity deials. Such deial letters should iclude a detailed explaatio of why the patiet does ot meet the pla s cliical criteria ad a descriptio of the evidece reviewed by the pla, ad should address evidece submitted by the patiet or their provider. Without such iformatio, it ca be very difficult to lodge a meaigful appeal. Admiistrative Appeal: The secod etry poit is to file a admiistrative or grievace procedure appeal. This type of appeal typically addresses a o-cliical issue ad is filed whe there is a dispute about the level of beefits covered by the specific health pla, such as a o-covered beefit or exclusio. Some types of deial based o exclusios, such as experimetal treatmet deials, may be appealed via the medical ecessity pathway. The Keedy Forum www.thekeedyforum.org 5
Filig A Appeal Based O a Parity Violatio Both etry poits ca be used to lodge a complait ivolvig a potetial parity violatio, depedig o the specifics. Ufortuately, the appeals process is complicated ad varies depedig o the type of isurace you have. The iitial appeal with the health pla, also referred to as the iteral appeal, may have oe to three levels of review depedig o the patiet s isurace coverage. I additio, differet timeframes ad process requiremets exist depedig o whether the appeal is based upo a pre-authorizatio or prospective review (before the care is redered), cocurret review (while the patiet is receivig iitial care), or retrospective review (after the care has bee redered ad reimbursemet is beig sought). The urgecy of the requested medical care, as determied by the attedig provider, will also have a impact (i.e. stadard care versus urget care). A appeal ca usually be lodged over the phoe, but it is advisable to keep otes about all coversatios with health plas (icludig date, time, ame of health pla represetative, ad iformatio discussed), ad to follow up i writig to create a record of the appeal. To optimize the chace of a appeal beig successful (i.e. overturig the origial decisio to dey care), the patiet or their attedig provider must carefully idetify ad documet the reasos why the isurer should cover the requested procedure or service. The medical ecessity review criteria used by health plas may have built ito their stadards some flexibility to accommodate patiets who could beefit from the additioal procedures or services. Clarity, documetatio ad persistece is key. I additio, desigated timeframes are required to be followed durig the appeals process. The health pla is resposible for providig iformatio o ay such appeal requiremets to the patiet at the time of iitial erollmet, whe a service is deied ad durig the appeals process. To optimize the chace of a appeal beig successful (i.e. overturig the origial decisio to dey care), the patiet or their attedig provider must carefully idetify ad documet the reasos why the isurer should cover the requested procedure or service. If possible, the attedig provider should draft a letter of medical ecessity that explais why the patiet satisfies each elemet of the health pla s medical ecessity criteria, ad otig why the pla s reasos for issuig the deial are flawed. The attedig provider should also iclude with the letter ay importat cliical iformatio (icludig medical records) that may ot previously have bee supplied to the health pla. For example, if a patiet with a metal health diagosis such as major depressive disorder is also sufferig from a opioid use disorder, the health pla should be made aware of both diagoses, as the patiet may require more itesive treatmet. 6 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio After the iteral appeal process has bee exhausted, the isured idividual, family member, attedig provider or advocate may be able to file a exteral appeal. A idepedet review orgaizatio (IRO) is typically resposible for reviewig the appeal at this jucture. Agai, timeframes ad process requiremets will vary depedig o the type of isurace coverage. Throughout the appeals process, the patiet or advocate should also cosider filig a appeal or complait with the followig etities, particularly if they feel that they are gettig stoewalled or otherwise beig short-chaged regardig their rights: A state or federal govermet agecy which oversees the patiet s health pla A accreditatio agecy which has accredited the patiet s health pla A arbitratio claim or court actio. Parity Violatio Explaied Whe a adverse beefit determiatio ivolves a claim or treatmet for behavioral health services, some additioal due process protectios ca come ito play. I fact, the Federal Parity Law ad related state laws impose requiremets that ca provide additioal grouds for patiets ad their attedig providers to appeal health pla deials. While the Federal Parity Law does ot require a health isurace pla to offer behavioral health services, plas that choose to offer such beefits must provide them i a maer that is equitable to medical/surgical beefits. For example, if a pla covered as may appoitmets as eeded with a immuologist, but oly covers five appoitmets with a psychiatrist, this limitatio would likely violate the Federal Parity Law. The Affordable Care Act (ACA) expaded the protectios provided by the Federal Parity Law. Prior to the ACA, the Federal Parity Law oly applied to large group employers, Medicaid maaged care, ad Childre s Health Isurace Program (CHIP) plas. Followig the ACA, qualified health plas (idividual ad fully-isured small group health plas offered i ad outside the health isurace exchages) must iclude behavioral health beefits at parity as a essetial health beefit offered to members. Additioally, the beefits offered to the Medicaid expasio populatio must iclude behavioral health beefits, ad some states require that fully isured plas provide such beefits. A parity law violatio ca take may forms. Some policies ad practices covered uder the parity law are easily measured by a dollar amout or a umber. This icludes, for example, fiacial requiremets such as co-paymets or deductibles, ad quatitative treatmet limits (QTLs) such as day ad visit limits. Uder the Federal Parity Law, fiacial requiremets ad QTLs caot be more restrictive for behavioral health services tha for medical services i the same class of beefits. The Keedy Forum www.thekeedyforum.org 7
Filig A Appeal Based O a Parity Violatio Other health pla practices or policies that limit beefits are called o-quatitative treatmet limitatios (NQTLs) because these limitatios caot be measured by a dollar amout or umber. The basic rule is that a health pla caot impose a NQTL that is ot comparable, or that is applied more strigetly, to behavioral health beefits tha to physical health beefits. Examples of NQTLs iclude, but are ot limited to: Limits o the quatity or frequecy of treatmet: If a health pla requires a automatic review after a arbitrary day or visit limit has bee reached for metal health or substace use disorder treatmet, but does ot require such a review for medical or surgical beefits, the health pla may be i violatio of the Federal Parity Law. More restrictive prior authorizatio policies for behavioral health: May health plas require prior authorizatio for o-emergecy ipatiet facility or hospital services, both for medical surgical ad behavioral health care. However, if a health pla s prior authorizatio procedure routiely approves up to seve ipatiet days for medical services but just three ipatiet days for behavioral health ipatiet services, the pla is likely i violatio of the Federal Parity Law. The parity violatio is the result of the health pla applyig the prior authorizatio process more strigetly to behavioral health services. Excessive cocurret review policies: Whe a patiet is admitted to a ipatiet or residetial treatmet facility or day treatmet, or eeds log-term outpatiet couselig, health plas may periodically review the medical ecessity of the treatmet by a process kow as cocurret review. If health plas require cocurret review too frequetly or impose overly burdesome requests o behavioral health care providers as compared with medical care providers to justify cotiued treatmet, the pla may be i violatio of the Federal Parity Law. Step therapy or fail-first protocols: Sometimes health plas require patiets to try ad fail at a lower level of care before they will approve a greater beefit. For example, a pla may require patiets to try itesive outpatiet services or partial hospitalizatio for behavioral health treatmet before they will approve ipatiet treatmet. The pla is i violatio of the Federal Parity Law if it does ot have a fail-first requiremet i place for obtaiig ipatiet medical treatmet. Some of these parity issues, such as impositio of fail-first protocols, may be relatively easy to spot i a coverage deial. However, other issues, such as excessive cocurret review policies, are harder to idetify. I both cases, additioal iformatio is eeded about the pla s policies ad procedures to determie whether behavioral health beefits are beig admiistered more strigetly tha physical health beefits. 8 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio The Federal Parity Law reiforces ad augmets health plas obligatios regardig trasparecy ad disclosure of iformatio used i makig a adverse beefit determiatio. Specifically, plas are required to provide to cosumers, free of charge: The specific reaso for the deial of the requested service or claim A copy of the plas medical ecessity or beefit criteria for behavioral health (plas must provide this o request to ay perso) The pla s medical ecessity criteria for medical/surgical beefits The Federal Parity Law reiforces ad augmets health plas obligatios regardig trasparecy ad disclosure of iformatio used i makig a adverse beefit determiatio. A descriptio of the pla s processes, strategies, evidetiary stadards ad other factors used to apply oquatitative treatmet limitatios (e.g., prior authorizatio policies, step therapy protocols, geographic restrictios) for both physical ad behavioral health beefits. I sum, upo request, plas must supply details regardig their parity compliace review ad testig process, icludig ay medical maagemet procedures used i makig medical ecessity determiatios. Such iformatio must be specific. For example, geeral statemets that a health pla complies with parity, or that the pla applies the same set of factors to determie utilizatio maagemet procedures for physical ad behavioral health beefits, are isufficiet. Because the Federal Parity Law requires comparable applicatio of utilizatio maagemet practices, the disclosure of detailed iformatio for both the behavioral health treatmet at issue ad a comparable physical service is ecessary to determie if a parity violatio took place. Ideally, the cosumer will have this iformatio i had before submittig a appeal, but i may situatios (especially if the deied treatmet is urgetly eeded), a appeal will eed to be lodged i cojuctio with a request for parity compliace iformatio. To lear more about parity appeals, check out the Parity Resource Guide at www.thekeedyforum.org. The Keedy Forum www.thekeedyforum.org 9
Filig A Appeal Based O a Parity Violatio Filig a Parity Appeal If this iformatio appears complicated, you are ot aloe. I fact, the appeals process is so dautig that fewer tha oe out of 10,000 eligible idividuals request a exteral review of a deied health care claim. 4 However, the good ews is that persistece ca pay off. Data collected by the U.S. Govermet Accoutability Office (GAO) foud that 39 to 59 percet of iteral appeals were reversed i favor of the cosumer. 5 This tred also cotiued for exteral review of deied claims a study coducted by America s Health Isurace Plas (AHIP) foud that 40 percet of exteral appeals were reversed i favor of the claimat i 2003 ad 2004. 6 If a patiet, patiet s family or provider believes care has bee ulawfully deied, a good first step is to file a appeal with the health pla s cliical or admiistrative appeals system. Addig a parity law compliace challege to the appeal will require a health pla to provide additioal disclosure of iformatio, documets, ad the pla s parity compliace review ad testig process. The patiet or their advocate should review the pla s appeals process ad timeframe requiremets ad be prepared to jump through some of the bureaucratic hoops associated with most appeals. Additioally, patiets, providers, frieds ad family members should cosider registerig a complait with the Keedy Forum s Parity Complait Registry ad Appeal Resource. This olie tool was created to provide valuable iformatio ad resources for those preparig to register a complait or a appeal with a health pla or regulatory agecy. By registerig a complait with www.parityregistry.org, patiets ca help the Keedy Forum idetify, collect ad documet importat iformatio to use with regulators ad health plas to correct problems ad develop solutios. The data will also help us to study regioal ad atioal treds o the types of parity violatio complaits that are beig filed. This will help with makig a data-drive case to policymakers to improve behavioral health coverage. By registerig a complait with www.parityregistry.org, patiets ca help the Keedy Forum idetify, collect ad documet importat iformatio to use with regulators ad health plas to correct problems ad develop solutios. 10 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio Call to Actio: Te Steps Although may success stories exist where a patiet or orderig provider s appeal was hadled i a timely ad efficiet maer by a health pla, those cases are the exceptio ad ot the orm. The good ews is that the buildig blocks to achieve true parity implemetatio are ow i place, but more remais to be doe. The followig te steps will advace metal health parity by improvig the appeals process for all: 1. Icrease Awareess of the Appeal Process. The appeals process is eormously complex. May idividuals do ot kow they have the right to file a appeal upo receivig a adverse beefit determiatio. Health plas ad regulators should work together to esure that all erollees are aware of their rights through targeted public educatio campaigs. Regulators should also reiforce health plas parity disclosure requiremets ad make clear that i both iteral ad exteral appeals, a parity violatio is grouds for reversal of a coverage deial. 2. Promote More Due Process ad Trasparecy. Whe a adverse beefit determiatio or deial takes place, more trasparecy must be provided surroudig how the decisio was made ad documeted. At a miimum, health plas must disclose the cliical ad/or coverage criteria used i the decisio ad clearly explai the specific steps required to file a appeal. Regulators should also eforce requiremets that deial letters iclude a detailed 1 Icrease Awareess of the Appeal Process 3 Allow Attedig Providers ad other Advocates to File Appeals 5 Stadardize the Appeal System Across Market Segmets ad State Lies 7 File More Appeals 9 Update Regulatory Oversight Mechaisms explaatio of why the patiet does ot meet the pla s cliical criteria, a descriptio of the evidece reviewed by the pla, ad address evidece submitted by the patiet or their provider. Otherwise, cosumers caot avail themselves of their appeal rights. 2 Promote More Due Process ad Trasparecy 4 Simplify the Appeals Process 6 Upgrade the Exteral Review Appeals Process 8 Leverage Techology to Improve the Efficiecy of the Appeals Process 10 Promote Advocacy ad Sposor Educatio Programs The Keedy Forum www.thekeedyforum.org 11
Filig A Appeal Based O a Parity Violatio 3. Allow Attedig Providers ad other Advocates to File Appeals. I some istaces, orderig or attedig providers are ot allowed to file a appeal o behalf of their patiets. This is couterituitive ad iefficiet as the provider is ofte i the best positio to uderstad the deial decisio ad the explai why the service or treatmet is still recommeded or why the care was already delivered. Providers also have a leg-up as they are familiar with the medical jargo used i the deial letter or throughout the appeals process. 4. Simplify the Appeals Process. May patiets ad orderig providers complai that too may bureaucratic hurdles ad icosistet requiremets exist withi the appeals process. These obstacles have a chillig effect that discourages patiets or their represetatives from filig a appeal. Origially, the appeals process made clear that utilizatio maagemet (UM) appeals hadled medical ecessity or cliical deials, ad grievace procedure appeals hadled admiistrative deials. Today, model laws from the Natioal Associatio of Isurace Commissios (NAIC) ad may jurisdictios have issued regulatios that have eroded this formerly clear bifurcatio. We recommed that oe itegrated ad streamlied appeals process apply o matter the basis of the iitial deial. 5. Stadardize the Appeal System Across Market Segmets ad State Lies. A atioal ad cosistet stadard must be implemeted to make the appeals process effective. At preset, may differet appeal pathways exist. These pathways vary based o how the health pla is regulated, the type of coverage provided, the type of pla sposor, the jurisdictio, the type of deial (e.g., based upo a medical ecessity or beefit determiatio), the timig of the deial (e.g., prospective, cocurret ad retrospective), the urgecy of the care beig requested (i.e. stadard care versus urget care), ad where the patiet is i the appeals process. Our goal should be to establish oe atioal appeals stadard that promotes trasparecy, fairess ad due process to all parties ivolved. We ca accomplish this uified system through ew model legislatio, accreditatio stadards ad Requests for Proposal (RFP) requiremets. 6. Upgrade the Exteral Review Appeals Process. Curretly, the patiet or their authorized represetative must specifically request a exteral review of their claim. I most cases, the exteral review appeal oly ca be pursued after a patiet first successfully completes a appeal through the health pla. I some istaces, the aggrieved party may ot eve kow they have the right to appeal to a exteral party. Oe simple way to address this cofusio is to automatically refer the appeal to a idepedet review orgaizatio after the iteral appeal is completed. For example, Medicare beeficiary appeals are automatically referred to the exteral review level, resultig i more due process. 12 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio I additio, the exteral review process as curretly regulated should be re-examied ad potetially upgraded to better protect cosumers. Ideas iclude: Reviewer Idetificatio. I may cases, the patiet does ot kow who made the fial rulig durig the exteral review. Should the idetity of the exteral reviewer be revealed or remai aoymous? Does due process require the perso makig the judgmet to be disclosed like a judge i court? The Keedy Forum recommeds that the idetity of the reviewer be routiely disclosed. Public Disclosure of Decisios. I some states, regulators post de-idetified exteral appeal decisios o their websites, a practice that allows cosumers ad providers to uderstad the types of issues beig set to exteral appeals, how exteral decisios are made, ad to idetify treds (such as frequet overturs of deials of coverage for specific treatmets). Greater disclosure of exteral appeal decisios would beefit idividual cosumers ad help frame dialogue with health plas regardig practices that should be reformed. Paymet. I most cases, health plas cotract with two or more exteral review orgaizatios to hadle the exteral reviews of their isured populatio. Does the exteral review orgaizatio have a icetive to rule i favor of the health pla if the health pla also is payig for the cost of the exteral review? Should the patiet s health pla pay for the exteral review? Or should it be fuded by a govermet agecy or through some sort of fud supported by all health plas i a particular jurisdictio? The Keedy Forum recommeds that some sort of paymet system be set up through the local jurisdictio rather tha through the health pla to avoid ay perceived or real coflicts of iterest that might bias the exteral review decisio i favor of the health pla. Exhaustig Iteral Review. Should the patiet or their advocate always have to exhaust the health pla iteral appeals process before filig a exteral appeal? Should the patiet have the right to skip right to exteral review? The Keedy Forum recommeds that the patiet be permitted to skip the iteral UM appeals process ad go right to exteral review if that is their decisio. However, oce this decisio is made, the patiet or their advocate loses the right to use the health pla s iteral appeal system for that particular issue uder dispute. The Keedy Forum www.thekeedyforum.org 13
Filig A Appeal Based O a Parity Violatio 7. File More Appeals. While workig to lower the umber of deials issued o claims, stakeholders should simultaeously work to esure that every questioable deial is subjected to the appeals process so that erollees receive the care they are etitled to. Each stakeholder group should do the followig to promote the filig of appeals: Cosumer/Provider. Every patiet who has experieced a deial or care restrictio of metal health or addictio services should file a complait at www.parityregistry.org ad/or with the applicable govermet agecy. Filig a complait will help us develop comprehesive data to better uderstad the differet types of parity deials. Idustry. Whe a appeal is filed, health pla persoel must make a good faith effort to respod i a timely ad meaigful maer. Health plas ad medical maagemet orgaizatios must esure they are complyig with existig regulatios ad the patiet s pla documets o how these appeals should be processed (e.g., timeframes, disclosure requiremets). Policymakers/Regulators. Policymakers ad public officials must esure they eforce existig state ad federal regulatios o how appeals should be filed ad processed. I additio, the curret regulatory ad accreditatio requiremets should be updated to create a more efficiet ad effective appeals process for all parties. 8. Leverage Techology to Improve the Efficiecy of the Appeals Process. Much like TurboTax has helped tax filers, it is time to leverage techology to promote a more efficiet appeals process. All too ofte, the appeals process is still paper-based or otherwise very fragmeted. While www.parityregistry.org is oe step i the right directio, more ca be doe. 9. Update Regulatory Oversight Mechaisms. It is time to update regulatios to capture recet treds i how best to moitor ad promote the appeals process. This could iclude updatig the model laws, regulatios ad accreditatio stadards coverig utilizatio maagemet, grievace procedures, exteral review ad metal health parity compliace, both at the federal ad state levels. It also could iclude promotig value-based ad outcome measures. Regulatios eed to keep pace with chages i health care delivery, techology capabilities, ad commuicatio platforms. 14 The Keedy Forum www.thekeedyforum.org
Filig A Appeal Based O a Parity Violatio 10. Promote Advocacy ad Sposor Educatio Programs. States should sposor ad subsidize experts who ca help patiets uderstad, file, ad process appeals by creatig cosumer advocate offices, like the Office of the Health Care Advocate i Coecticut or Health Law Advocates i Massachusetts. Regulators ad health isurers ca support this effort through customer service lies, supplemetal educatioal programs, broker materials ad other resources that are specific to their agecy or pla. These agecies should also actively coect cosumers iterested i filig a appeal with o-profits capable of supportig idividuals throughout the process. Fial Thoughts The appeals process, especially for parity violatios, remais a complex ad cofusig system for most stakeholders. It is time to rethik ad improve o existig appeal systems with a eye towards makig the appeals process more efficiet, trasparet ad meaigful. The impact of doig so will be meaigful for idividuals ad their families who eed ad deserve care ad are etitled to services. For more iformatio o this topic, cotact Garry Careal, JD, Seior Policy Advisor, The Keedy Forum, at ifo@thekeedyforum.org. See also www.thekeedyforum.org. The Keedy Forum www.thekeedyforum.org 15
Filig A Appeal Based O a Parity Violatio About The Keedy Forum A Message from Patrick J. Keedy I fouded The Keedy Forum i 2013 as a way to covee cuttig-edge thikers who are uited by the potetial for reform i behavioral health service delivery made possible by ew laws, revolutioary techologies ad a ehaced uderstadig of effective services ad treatmets. Our iaugural evet i October of that year called for The Forum to develop a platform to advace thikig across a host of issues i our field. To meet this demad, The Keedy Forum is orgaized as a thik tak poised to drive real, lastig ad meaigful policy chage to brig the atio closer to fulfillig Presidet Keedy s visio as outlied i the 1963 Commuity Metal Health Act. Today, The Keedy Forum s work is ot sigular i its focus. We are promotig metal health coverage through a series of iitiatives, which iclude: Esurig health pla accoutability ad compliace with the letter ad spirit of the parity law by educatig cosumers, providers, ad regulators, so that each group holds themselves ad others accoutable for proper eforcemet. Establishig ways to promote provider accoutability through evidece-based outcomes measures that are validated ad quatifiable. Implemetig prove collaborative practice models that promote the itegratio of metal health ad substace use disorder services ito maistream health care. Usig techology to optimize electroic/digital commuicatios ad ehace assessmet/treatmet tools. Promotig brai fitess ad welless, which icludes idetifyig opportuities to traslate eurosciece research fidigs ito prevetive ad treatmet itervetios. Please visit our website, www.thekeedyforum.org, to track our ogoig activities i support of these five iitiatives ad other activities cetral to The Keedy Forum s missio. Patrick J. Keedy Fouder 16 The Keedy Forum www.thekeedyforum.org
Edotes 1 CCIIO. The Metal Health Parity ad Addictio Equity Act. Retrieved from https://www.cms.gov/ cciio/programs-ad-iitiatives/other-isuraceprotectios/the Federal Parity Law factsheet.html 2 GAO. (2011). Private Health Isurace: Data o Applicatio ad Coverage Deials. Retrieved from http://www.gao.gov/ew.items/d11268.pdf 3 Cosumers Uio. (2015). Surprise Medical Bill Survey: 2015 Natioally-Represetative Olie Survey, Cosumers Uio May 5, 2015. See http:// cosumersuio.org/wp-cotet/uploads/2015/05/ CY-2015-SURPRISE-MEDICAL-BILLS-SURVEY-REPORT- PUBLIC.pdf 4 AHIP. (2006) A Update o State Exteral Review Programs. https://www.ahip.org/pdfs/exteral_ ReviewJa06.pdf 5 GAO, supra. 6 AHIP, supra.