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					California Department of
 Managed Health Care
              Tom Gilevich
“Independent Medical Review (in Health Care
            Delivery Systems)”

                 May 2, 2003
            Los Angeles, California
Independent Medical Review - IMR
   (External review)

  An informal resolution of selected disputes
  over health care services from an HMO,
  health insurer or other third-party payer

  • Impartial and independent
  • Dispute-specific assessment
  • The last informal process available
Treatment Authorization Process
Initial Denial
Internal Grievance & Appeal

After the plan has its shot …..

 Complaints to Dept. of Managed Health Care
    HMO Helpline: (888) HMO-2219
Purpose of IMR

  • “Restoring confidence in managed
    • Consumer demand for safeguards
    • Public policy accommodation
    • Industry acceptance

  • 42 states; Medicare; TRICARE
California IMR system (Cont’d)

  • Written determinations by reviewers provided
    to all parties

  • Adopted by DMHC and binding on plan

  • Civil action against plan requires exhaustion of
    IMR process
California IMR system

Three types of disputes are eligible:
            - Experimental denials
            - Medical necessity denials
            - Denied reimbursement for
              emergency/urgent services

Not coverage issues – plan determinations based on
a finding the disputed services are not medically
California IMR system (Cont’d)

•   Completed internal grievance system
•   One page application – no cost to applicant
•   No threshold for amount in dispute
•   Department determines eligibility
•   State contracts with review organizations
•   Health plan provides information
•   Qualification & conflict screening of reviewers
Distinctions among IMR systems

  •   When is it available – what does it decide
  •   Automatic or application
  •   Control, payment and administration
  •   Reviewer selection
  •   Standards & evidence used
  •   How does it work – “due process”
  •   Review and monitoring or reviews
  •   Consequences if not utilized
More information ---
DMHC Website: www.dmhc.ca.gov
 Forms and FAQs
 IMR case summaries

HMO Helpline: (888) HMO-2219

Reports: Kaiser Family Foundation www.kff.org
    Calif. Healthcare Foundation www.chcf.org

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