1. Appeals Handled by The Office of the Healthcare Advocate
UConn Health Disparities Institute
Sept. 7, 2018
Appeals Handled by The Office of the Healthcare Advocate
Ted Doolittle – State Healthcare Advocate

2. What is OHA? Independent state agency
Free assistance to any consumer with questions about health insurance or plan selection
Represent consumers in insurance denials
Speak for health insurance consumer on policy with government, industry and other stakeholders

3. Assist and educate consumers when selecting a health plan
Explain insurance plans, benefits, cost-sharing to consumers to assist with plan selection and maximize utilization
Educate consumers on their health insurance rights and how to advocate on their own behalf
Answer questions and assist consumers in appealing a health plan’s denial of a benefit or service.

4. Help consumers resolve problems with their health insurance plans
Any CT resident who requests our help with a health related issue or anyone with a policy written in CT
Fully or self insured
Public or private
Exchange or non-Exchange
Case Management (assess, coordinate, monitor and evaluate options and services required to meet an individual’s health or advocacy needs)

5. Consumer calls or complaints.
2017:
6,023
Consumer calls or complaints.

6. 2017: $10.2 million Consumer savings

7. Savings per consumer call.
2017:
$1,694
Savings per consumer call.

8. OHA continues to provide consumers with much- needed education and assistance on appeals, peer to peer review, pre-authorization and concurrent reviews.

9. .

10. .

11. Mental health largest category

14. OHA lacks reliable data due to data entry idiosyncracies
Appeal Type
OHA lacks reliable data due to data entry idiosyncracies
Observationally, vast majority of our appeals are medical necessity
Carrier’s medical experts disagree with treating provider
Experimental & unproven

15. Other identifiable categories:
Appeal Type, ctd.
Other identifiable categories:
Out-of-network disputes
Eligibility & enrollment (i.e., disputes over whether coverage exists; e.g., premium payment disputes, COBRA issues)
Plan benefits disputes (i.e., covered vs. non-covered; preventative vs. diagnostic)
Billing/coding disputes

16. Medical Necessity Appeals
OHA must obtain & review medical records
Utilize OHA in-house clinical expertise or treating provider expertise
Medical literature research
Write appeal letters
Follow appeal levels within carrier, then external review
Estimated ultimate success rate well over 50%
But estimated 1st level (internal) success rate much lower

17. Medical Necessity Appeals Solutions
Hypothesis: consumers who do not seek expert assistance much less likely to appeal and/or prevail
Carrier internal review process is not catching many cases that will ultimately be overturned
Internal reviews ineffective
Causes: high caseloads; quick turnarounds; 1st level reviewers do not have the benefit of systematic gathering of medical records, clinical evidence, and marshalling the story
Could be causing consumers to abandon valid appeals
Should carriers be re-directing resources to more/faster external review?

18. Medical Necessity Appeals Solutions
Hypothesis: Many legitimate medical necessity claims are not pursued
Large scale medical claims litigation model:
Review many claims; then extrapolate the result
Could this model be used by large insurance plans
Annually randomly pull and review statistically significant sample of unappealed denials
Determine incorrect denial rate
Use money to reduce premium next year
Logistical barriers; expense; gathering/reviewing medical records labor intensive

19. Medical Necessity Appeals Solutions
Analogous medical claims review & extrapolation effort: CMS’s Probable Fraud Measurement Pilot
Effort to review nationwide Medicare Home Health claims to determine probable fraud rate in the sector
Intensive design & preliminary work by CMS’s Center for Program Integrity
Cost estimates were several million dollars
Seems to have been lost in transition to new administration

20. Medical Necessity Appeals Solutions
Industry should fund programs like OHA offering free expert appeal assistance in more states
Medical necessity denials should be presumptively appealed or automatically reviewed by another level
Internal carrier 1st level appeal processes could be audited/reviewed for effectiveness
Rotate medical professionals responsible for internal peer review, just as businesses must rotate auditors periodically

21. Questions? 860-331-2441 Healthcare.Advocate@ct.gov