AMCNO Meets with Ohio Department of Insurance regarding prompt pay and external review issues

The Ohio Department of Insurance (ODI) convened a meeting of physician/provider groups to discuss how ODI handles prompt pay and external review issues. In brief, the ODI staff noted that they receive about 2,000 complaints a year from providers, however, over one-half of the complaints involve ERISA plans, Medicaid/Medicare or Federal Employee Benefit Plans and under the law these are all outside the jurisdiction of ODI, so only about 1,000 prompt pay complaints are evaluated by ODI each year.

Fifty percent of those reviewed are submitted to ODI are not prompt pay issues and involve denials or other insurance issues and are not reviewed. Of the complaints that were valid and filed in 2007 – 27% of these were reversed or payments were made to the providers. ODI staff noted that it is important that physicians/providers understand that they have to go through the insurance company internal appeals process first before filing a complaint with ODI. Currently, no reports on prompt pay complaints are issued by ODI. AMCNO and other groups in attendance voiced concern that this information was not readily available and asked that ODI consider preparation of such reports for dissemination. It would be helpful to know what type of complaints are processed, how many involve hospitals, physicians or other provider types and what percentage are reversed each year. In addition, a breakdown by category of complaint and insurance company involved would be helpful. ODI plans to review this request and respond back to the AMCNO.

The next topic discussed was the Ohio Patient Protection Act. With regard to the external review process, ODI staff stated that an external review by an independent review organization (IRO) can only be done after the consumer has completed the health plan internal review process. After a consumer has been told that they have been denied by the insurance company there must be, by law, included on the explanation of benefits form or denial letter that is sent to the patient a notation from the insurance company stating that they are entitled to an external review process. This review could occur if it involves a medical necessity issue over $500.00 and if the member can show that the provider states that the service is needed; or it involves an experimental investigational therapy for a terminal illness with a probable cause of death within 2 years. The health insurance company would file the request for review and the IROs are randomly selected. 

When the IRO makes their decision the decision is binding on the health plan but not on the member – they can seek legal counsel.

The AMCNO raised the question regarding the issue of medical necessity and what was the definition of “medical necessity” utilized in the review process and did the IROs use a specific definition of medical necessity when making their decision. The ODI staff provided a brief overview of the Ohio statutes but then indicated that they need to research this further and respond back to both the AMCNO and the group on the medical necessity issue. 

There was concern expressed by both the AMCNO and the group that the ODI appeal/external review process did not provide better consumer and physician/provider notice of the appeal process and outcome. At this time, the physician/provider is not aware of the appeal and do not receive information on the outcome. A discussion ensued of the value of a one-page document that outlined the rights and process of physicians and patients along with the requisite notice. ODI plans to prepare an explanatory document on the rights of consumers to an external review and provide this information to the AMCNO and the group for dissemination to association members. 

Concern was voiced about the status of Medicaid Managed Care plans in the state of Ohio and the group requested that the ODI put together a work group to discuss these plans and how they operate in Ohio. It was noted that the Ohio Department of Job and Family Services recently reconstituted the Medicaid Advisory Committee to review these plans – but the group felt that an additional committee through ODI would be needed.