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Friday, January 21, 2000

HMSA chooses
independent reviewers
for member appeals

The two firms will handle disputes
HMSA cannot resolve
with its members

By Helen Altonn


Hawaii Medical Service Association members who dispute decisions about the medical appropriateness of their eligible benefits now have a new source of appeal.

HMSA has selected two mainland organizations to provide an independent review of appeals of such decisions.

Fred Fortin, HMSA vice president of policy and planning, said the state's largest health insurance carrier "has traditionally used community physicians and other outside expert practitioners to supplement the decisions of its medical directors."

Now, he said, HMSA members "have the additional layer of security that a formal independent review process provides."

For example, Fortin said, if a patient wants a procedure done and there is no indication in literature that it is common for the diagnosis, HMSA may say after looking into it that it's not medically appropriate.

If the patient disagrees, HMSA will conduct an internal review with its medical directors and physician experts.

If the denial is upheld at that level and the member still isn't satisfied, the next step would be to gather any documents from HMSA, the patient and his or her physician and send them to an independent review organization, Fortin said. They will be paid a fee for each review.

More appeals possible

Fortin said the average number of appeals received by HMSA is fewer than "a couple dozen" a year. "We try to work in members' behalf." But he said some cases are very difficult, and the number of appeals may increase as consumers get more active and understand the process.

Mike K. Sayama, vice president of health benefits management for HMSA, is overseeing the expanded appeals program with the association's medical directors.

Sayama said urgent appeals requiring independent review will be handled within 72 hours and HMSA will honor all decisions made by the physician experts.

The independent review will apply to decisions in HMSA's Preferred Provider and HMO plans.

After analyzing independent review organizations across the country, HMSA said two met its "rigorous standards for quality and timely medical reviews." They are:

Bullet The Center for Health Dispute Resolution, which has completed more than 50,000 reviews for Medicare, state regulatory agencies and commercial health plans since 1998. It is the nation's original and largest independent external review provider, HMSA said.

Bullet The Medical Care Management Corp., which has more than 500 board-certified physician reviewers associated with more than 100 leading medical centers. MCMC has more than 200 corporate clients, including many of the largest managed care plans and health insurers in the nation, HMSA said.

Fortin said HMSA will honor any decision the independent reviewers make. If the opinion upholds denial, that will complete HMSA's internal review, he said.

Members who remain unhappy about the outcome can go into arbitration with HMSA or appeal to the state insurance commissioner, a route provided under the state's patient's rights law. Medicare, Medicaid and the Federal Employees Health Benefits Program also have appeals processes.

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