BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1410
AUTHOR: Hernandez
AMENDED: March 29, 2012
HEARING DATE: April 11, 2012
CONSULTANT: Rubin
SUBJECT : Independent medical review.
SUMMARY : Requires the Department of Managed Health Care (DMHC)
and the California Department of Insurance (CDI) to collaborate
on a common searchable database of all Independent Medical
Review (IMR) cases that includes specified information, and
increases the expertise standard that clinicians must meet in
order to review IMR cases.
Existing law:
1.Requires the licensing and regulation of health care service
plans (health plans) by DMHC, and requires the licensing and
regulation of health insurers by CDI.
2.Requires DMHC and CDI to establish an IMR system under which
an enrollee or insured must seek an external IMR whenever
health care services have been denied, modified, or delayed by
a health plan or insurer (collectively "carriers") and the
enrollee or insured has previously filed a grievance that
remains unresolved after 30 days.
3.Requires medical professionals selected by an IMR organization
to review medical treatment decisions to meet certain minimum
requirements, including that he or she be a clinician
knowledgeable in the treatment of the patient's medical
condition, knowledgeable about the proposed treatment, and
familiar with guidelines and protocols in the area of
treatment under review.
4.Requires DMHC and CDI to adopt the determination of an IMR
organization as binding on the health plan or insurer.
5.Requires the IMR decisions to be made freely available, on
request, to the public, and requires certain information to be
removed from the decision before it is made available to the
public, including the name of the carrier.
Continued---
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This bill:
1.Requires the IMR application to include a section designed to
collect information about the patient's ethnicity, race, and
primary language spoken, and a statement indicating that the
provision of the information is optional and used only for
statistical purposes.
2.Requires the medical professionals selected by an IMR
organization to be clinicians expert in the treatment of the
enrollee or insured's medical condition and knowledgeable
about the proposed treatment through recent or current actual
clinical experience treating those with the same or a similar
medical condition.
3.Requires IMR decisions to be made available at no charge on
the website of DMHC and CDI, and eliminates the requirement to
remove the name of carriers from decisions, thereby allowing
them to be included in IMR case data that is made publically
available.
4.Requires DMHC and CDI to consult and coordinate with each
other regarding the establishment of a common searchable
database for these decisions, and specifies the information
that is to be made available in the database.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. According to the author, California's IMR
program allows a consumer of a health plan or health insurer
to receive an external IMR when coverage for a benefit or
service is denied. A recent report and briefing by the
California HealthCare Foundation (CHCF) examined over ten
years of California's IMR and concluded that administrative
improvements might be made to more effectively deliver the
promise of a credible, transparent, and effective IMR program.
SB 1410 will provide these improvements by requiring the
regulators to collaborate on a common, free, searchable
database of IMR cases that will include information beyond
what either department is currently providing, such as patient
race, ethnicity, and primary language spoken. SB 1410 will
additionally address the concern that reviewers are not always
appropriately qualified by requiring reviewer qualifications
to be reported in the database and by elevating required
reviewer expertise to the level advocated by federal law.
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2.Types of IMR cases. California's IMR provides for independent,
external review of three main types of disputed carrier
decisions: medical necessity, urgent/emergency care, and
experimental/investigational.
Medical necessity IMR cases occur when carriers deny, modify,
or delay requests for coverage of services in whole or in part
due to findings that the services are not medically necessary.
Medical necessity decisions are distinguished from coverage
decisions, which are reviewed directly by DMHC and CDI rather
than through IMR. Both covered benefits and medical necessity
are defined contractually and vary among carriers. According
to existing law, a medical necessity decision regarding a
disputed health care service relates to the practice of
medicine and is not a coverage decision, while a coverage
decision means the approval or denial of health care services
based on a finding that the provision of a health care service
is included or excluded as a covered benefit under the terms
of a health carrier contract. Carriers categorize their
decisions as medical necessity or coverage decisions, but DMHC
and CDI have the final authority as to how disputed decisions
will be categorized and appealed.
Urgent or emergency care IMR cases are for services already
received, when a carrier decides that the services did not
require urgent care and that the patient should have known
that an emergency did not exist even if a provider deemed the
services to be medically necessary.
Experimental or investigational IMR cases occur when carriers
deny coverage of services for patients on the basis that the
disputed service is considered experimental or investigational
by the carrier. In order for a patient to have access to IMR
under these circumstances:
a) The patient must have a life-threatening or
seriously debilitating condition;
b) The patient's physician must certify that the
patient has a condition for which standard services have
not been effective or medically appropriate, or for which
there is no more beneficial standard service covered by
the plan than the one proposed;
c) The patient's physician must have recommended or the
patient or physician must have requested a service which,
based on medical and scientific evidence, is likely to be
more beneficial than services that are standardly
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available;
d) The carrier must have denied coverage of the
service; and
e) The service would be a covered benefit except for
the carrier's decision that it is experimental or
investigational.
1.The IMR process. California's IMR requires that a patient must
first attempt to resolve a dispute through a carrier's
internal appeal or grievance process before seeking IMR.
Disputes that remain unresolved after a specified time period
can be appealed to DMHC or CDI, at which time the departments
must determine whether the dispute qualifies for IMR or is
rather considered a coverage dispute to be reviewed directly
by the departments. Cases determined to qualify for IMR are
reviewed by medical professionals selected by the independent
review organization contracted by DMHC or CDI. The reviewer or
reviewers in each IMR case receive information and documents
related to the case that are provided by the health carrier
and the patient and reviewed by DMHC or CDI. Reviewers must
meet standards that are intended to preclude conflicts of
interest and insure a suitable degree of knowledge about the
treatment of the patient's medical condition and the proposed
treatment. Once a reviewer determination is made, the Director
of DMHC and the Insurance Commissioner are required to
immediately adopt the determination as a director or
commissioner decision and issue a written decision to the
parties that is binding on the carrier.
2.California HealthCare Foundation report. In January 2012, CHCF
issued a report, "Ten Years of California's Independent
Medical Review Process: A Look Back and Prospects for Change,"
examining over a decade of IMR cases for lessons learned and
potential program improvements. The report reviewed the
history of IMR, types of cases, growth in the numbers and
rates of cases, demographic characteristics of cases, types of
diagnoses and treatments reviewed, and the rate of reversals
of carrier decisions. Included in the report were the
following findings:
a) The annual number of IMR cases has tripled between
2001 and 2010 from 614 to 1,831; the rate of IMR cases
has increased over the same time to 0.82 per 10,000
DMHC-regulated health plan enrollees (CDI IMR rates
cannot be calculated because CDI does not publically
report the number of people insured under its
jurisdiction).
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b) IMR appeals often overturn carrier decisions; in
2010, 46 percent of all IMR cases were overturned,
requiring the disputed health care services to be
provided.
c) IMR cases often involve new and emerging types of
treatments or services in areas where a consensus in the
medical community has yet to be reached. In-depth
analyses of IMR cases concerning bariatric surgery for
obesity and botox for migraines demonstrated how IMR
contributed to inform medical dialogue and health plan
decision-making.
d) Reviewers do not always meet IMR standards, either
by failing to document reasons for their decisions or by
not having appropriate credentials. (Maximus, the
independent review organization contracted by both DMHC
and CDI, responded that the specific examples cited in
the CHCF report do not constitute failures to meet IMR
standards but rather are examples where reviewer decision
rationales and reviewer credentials were not publically
available or made available to the researchers who wrote
the report).
The CHCF report concludes that "several primarily
administrative improvements might be made in �California's]
IMR, which would position the state to more effectively
deliver on the promise of a credible, transparent, and
effective IMR program." As an area for improvement, the report
suggests more transparent, consistent, and complete reporting
of IMR data by state regulators in order to enhance the
state's ability to monitor and adjust program effectiveness,
build public and provider confidence in the basic fairness of
the program, and provide for system learning about the
development of medical consensus on emerging treatments.
Specific suggestions made to address this area for improvement
include:
a) The provision of additional specified information
about IMR cases, processes, and results, including
information about race, ethnicity, and language in order
to provide a potentially valuable resource for examining
differences in health care access and health disparities;
and
b) CDI and DMHC collecting and reporting the same
complete and meaningful information through one common,
online, searchable database for all cases, including
detailed case summaries and other specified information.
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1.Prior legislation. AB 55 (Migden), Chapter 533, Statutes of
1999, created the IMR system and requires every health carrier
to provide those receiving coverage from these products with
an opportunity to seek an IMR whenever health care services
have been denied, modified, or delayed in cases where a
carrier deems the services to be medically unnecessary.
SB 189 (Schiff), Chapter 542, Statutes of 1999, established an
IMR process for experimental or investigational therapies;
requires the contracting of impartial, independent, accredited
entities for the purposes of the IMR process; and amends the
internal grievance processes of carriers.
2.Support. The California Pan-Ethnic Health Network writes in
support of SB 1410 and its requirement for DMHC and CDI to
collaborate on a more complete and standardized database of
IMR cases, arguing that the bill will allow for more effective
program use and oversight by consumers, carriers, regulators,
and policymakers by facilitating stronger assessments of IMR
use and better outcomes for all Californians including
communities of color. The California Psychiatric Association
(CPA) writes that by increasing the standards for clinicians
to participate as reviewers, SB 1410 continues the quest for
quality in the delivery of managed health care services, and
for helping safeguard the rights of patients to have access to
the very best, most appropriate medical care. The CPA
additionally recommends that a reviewer should be a physician
who is board certified or qualified to be board-eligible in
the medical specialty which is the predominant field within
which a particular treatment expertise is bestowed. The
Neuropathy Action Foundation writes that this bill is
especially important because it strengthens the minimum
standard for reviewers to participate in an IMR case. The
California Healthcare Institute argues in support of the bill
that by requiring IMR to be conducted by a clinician with
expertise in the enrollee's medical condition, SB 1410 ensures
that patients receive the most appropriate treatment when
coverage is initially denied. BIOCOM writes that SB 1410 would
significantly strengthen IMR by ensuring that reviewers are
well versed in both the condition in question and current
treatment options, thus providing a vital check to ensure that
consumers have access to quality medical care.
3.Support if amended. The California Association of Health Plans
(CAHP) writes in support of the provision of SB 1410 that
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increases reviewer standards, arguing that this specialty
match provision is appropriate because it will help ameliorate
potential inconsistency among IMR reviews and strengthen the
use of evidence-based medicine to support decisions that are
legally binding upon health plans. CAHP does, however,
indicate that its members question the value of listing only
the name of the health plan associated with specific IMR
cases, arguing that if it is in the public's interest to know
which health plans are involved in specific cases, then by the
same token the public should know which medical professionals
are being overturned or affirmed in their initial medical
necessity. CAHP requests that either the health plans not be
listed independently, or that both the plan and medical
professional or professionals involved in the initial medical
necessity determination be identified as well. Health Access
California (HAC) writes that SB 1410, by requiring IMR case
data to be made freely available on the DMHC or CDI website,
will allow the public to see which carriers are unjustifiably
denying care to members. HAC adds in its letter that proposed
amendments would add greater specificity to the data disclosed
about IMR decisions, and that better data about decisions will
allow carriers to update their definitions of medical
necessity and covered benefits.
SUPPORT AND OPPOSITION :
Support: BayBio
BIOCOM
California Healthcare Institute
California Orthopaedic Association
California Pan-Ethnic Health Network
California Psychiatric Association
Neuropathy Action Foundation
Oppose: None received.
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