Access to sub-specialty peer reviewers is one of the most important protections related to quality appeal decisions. Sub-specialty peer reviewers have the expertise to initiate meaningful dialogue with providers related to both treatment decisions and applicable coverage limitations.
Recent insurance industry comments related to healthcare reform indicate that peer reviewers are not always available, or available in a timely manner, in the specific sub-specialty needed.
“Some reviews need board-certified sub-specialists. This can create time delays because finding sub-specialists who have time available and who have not previously been involved in the same case can be difficult. Areas of particular concern are pediatric subspecialists and sub-subspecialists in oncology (e.g., therapeutic radiation oncology),” states Justine Handelman, Vice-President, Legislative and Regulatory Policy for BlueCross Blue Shield Associates.
Handelman’s comments were submitted to the Office of Consumer Information and Insurance Oversight and other agencies as part of the solicitation of comments federal external review process mandated under the Patient Accountability and Affordable Care Act (PPACA).
To emphasize the challenge of arranging sub-specialty peer reviews, Handelman cites the example that the American Academy of Pediatrics lists only 362 physicians nationwide as members who are board certified in pediatric hematology-oncology. See www.dol.gov/ebsa/pdf/1210-28876-0019.pdf for the full text of her comments.
Appeal protections, including access to specialty and subspecialty peer reviewers, depend on a number of variables such as the type of coverage and state peer review requirements. PPACA seeks to enforce more uniform appeal protections for both group and individual coverage as part of the Interim Rule on Internal Claims and Appeals and External Review Processes. A number of insurers have commented on the challenges and costs related to PPACA federal external review implementation but the comments widely confirm the importance of specialty peer review access.
“Reviewers should be limited to reviewing cases within their specific specialty. We recommend that IROs be required to have available, and assign, medical reviewers who have the requisite competence, by virtue of their education, training, and relevant expertise, to evaluate the specific clinical issues presented for review. Each IRO must have sufficient depth of reviewers in specialty disciplines to ensure that plan determinations are reviewed by providers with appropriate expertise, e.g., review of cardiology claims by cardiologists, behavioral health claims by behavioral health practitioners, etc. In our experience, medical reviewers who make determinations outside their areas of expertise frequently make flawed decisions on medical necessity and experimental treatment questions due to their unfamiliarity with typical decision presentations,” states a comment submitted by Teresa Berman, Senior Legal Counsel for Magellan Health Services (www.dol.gov/ebsa/pdf/1210-28876-0014.pdf).
Because of the potential shortage of sub-specialty peer reviewers, appeals should make very specific demands regarding the credentials of the appeal reviewer. While the PPACA external review requirements do no apply to grandfathered health plans, such grandfathered health plans may still offer peer review of denied claims in order to satisfy internal appeal review, state or existing federal Employee Retirement Income Security Act (ERISA) requirements. Use wording such as the following or customize the wording to cite potentially applicable legal protections related to the denial:
It is our position that your organization’s clinical review criteria may allow benefits for the sub-specialty care recommended by the treating physician. Attached are the medical records which demonstrate the complexity of care and need for the recommended care. As you know, many state and federal claim processing regulations require peer review of a health benefit denial. Therefore, we request that a board certified sub-specialist review the denial of benefits. If the medical records do not sufficiently demonstrate the medical necessity of the care provided, please have the sub-specialists responsible for the peer review to contact Dr. (treating physician) immediately. This will allow Dr. (physician) to more completely describe the necessity of this treatment.
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