The Health Policy Commission’s (HPC) Quality Improvement and Patient Protection Committee held a hearing Monday on proposed amendments to 958 CMR 3.000, the Office of Patient Protection (OPP) regulation governing health plan internal and external appeals procedures. The proposed amendments follow a listening session that OPP convened over the summer, and include consumer-friendly changes required by the Affordable Care Act (ACA) and Massachusetts state laws, as well as changes to provide additional clarifications and protections for consumers.
For example, some positive changes prompted by the ACA include a faster turnaround time for both expedited and non-expedited external reviews; more detail and clarity for information provided in consumer notices; allowing patients with urgent medical needs to file both expedited internal and external appeals simultaneously; and requiring refunds to consumers of the external review fee if the consumer wins the review. And those are just a few of the improvements.
During the hearing, the Committee heard oral testimony from InterQual/McKesson Health Solutions, National Association of Social Workers (NASW), Massachusetts Association of Health Plans (MAHP), Health Law Advocates (HLA) and Health Care For All (HCFA), and Massachusetts Association of Behavioral Health Systems (MABHS). Here are some of the points raised:
- Jacqueline Mitus, Senior VP of Clinical Development and Strategy for McKesson Health Solutions and Laura Coughlin, VP of InterQual Development, raised concerns that providing criteria for medical necessity determinations to the public at no cost could breach confidentiality under intellectual property law and that the complexity of such information could create consumer confusion.
- Jonas Goldenberg, Director of Clinical Issues and Continuing Education at NASW, recommended more stringent criteria for clinicians participating in review panels and advocated that services should be automatically continued pending the outcome of an appeals process.
- Sarah Gordon Chiaramida, VP of Legal Affairs at MAHP, expressed concerns that requiring diagnosis and treatment codes on adverse determination notices would be confusing and may breach privacy protections by revealing protected health information to third parties. She further voiced concerns that the amendments around increased availability of translation services would be too costly and administratively burdensome for the health plans.
- Clare McGorrian, Senior Staff Attorney and Director of the Commercial Insurance Appeals Program at HLA provided testimony on behalf of both HLA and HCFA. She advocated that medical necessity criteria should be determined by providers with more clearly defined clinical expertise and recommended that adverse determination notices more prominently display deadlines for action, especially for expedited appeals and continued coverage for ongoing treatment .
- David Matteodo, Executive Director of MABHS, suggested that providers reviewing appeals be required to be licensed in Massachusetts.
The Health Policy Commission is accepting written testimony and comments from the public until 12 noon on Tuesday, December 24, 2013. For details on how to submit testimony electronically or via mail, see the Hearing Notice.