What’s in a Name? Health Plan Physicians Deny Care Cloaked by AnonymityMadisyn Schmitz, JD, MHSA, RHIA, CPC Richelle Marting JD, MHSA, RHIA, CPC, CEMC, CPMA After the education that Physicians Advisors have received emphasizing Medicare Advantage plans’ obligation to ensure medical necessity decisions are made by physicians or other professionals with expertise in the service at issue, many Physician Advisors made it a practice to introduce themselves when entering a P2P and asking for the name and specialty of the physician with whom they were speaking. I received a flurry of messages on December 19 when it became apparent that UnitedHealthcare plan physicians would no longer be giving out their names during P2P nor signing denial letters. The impetus for the change is obvious: the tragic December 4th murder of UHC executive Brian Thompson sent shockwaves throughout the healthcare community. The public response was a mix of sympathy and, well, lack of sympathy. The latter highlights the unfortunate but growing frustration among the healthcare and consumer communities with health plans’ barriers to accessing healthcare services. Specifically, healthcare consumers are growing more frustrated with not only insurance plans but providers. Healthcare providers experience a higher risk of violence at work than most other professions. Violence that healthcare professionals are subjected to may stem from a number of stressors, not the least of which may include the stress that comes with medical diagnoses and care. A significant factor exacerbating stress during episodes of healthcare encounters can include health plan prior authorization challenges, coverage issues, and medical bills. While health plans may have the luxury of hiding behind a veil of anonymity, healthcare professionals do not enjoy the same benefit. Healthcare professionals are often the first to communicate the dreaded “denied” decision of a patient’s health plan to the patient. It begs the question: can health plans obscure the process by refusing to identify the individual who makes the decision to deny coverage a patient's healthcare services? The classic lawyer answer we were taught on the first day of law school comes to mind: It depends. Under federal Medicare Advantage rules at 42 CFR 422.566(d), if an MA organization intends to issue a partially or fully unfavorable medical necessity decision, it must ensure physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue, including knowledge of Medicare coverage criteria, reviews the matter before the MA organization issues the organization determination decision. While the exact same specialty isn’t required, expertise in the services at issue is a requirement. Additionally, the physician or other health care professional must have a current and unrestricted license to practice within the scope of his or her profession in their state. What you don’t find in these regulations is an explicit and affirmative obligation of the plan to identify the name or credentials of the physician making these determinations. State laws are often substantially similar, but there are states that do require the health plan physician’s name to be identified. The American Medical Association has a 50-state survey of state utilization management and prior authorization rules. These laws tend to apply to fully insured plans like exchange plans but could also apply to MA HMO plans that have to follow state law HMO rules in addition to federal Medicare Advantage rules. The AMA survey itself doesn’t identify if the state law requires identification of the physician, but one can research the laws cited for each state to better understand state-specific rules. For example, California HSC § 1367.01 requires “Any written communication to a physician or other health care provider of a denial, delay, or modification of a request shall include the name and telephone number of the health care professional responsible for the denial, delay, or modification”. What can you do if health plans stop providing sufficient information for you to determine whether the professional rendering an adverse coverage decision has the appropriate expertise in the services at issue to pierce the veil of anonymity? First, determine the type of health plan involved. If the health plan is a commercial plan, consider contacting your state’s Department of Insurance. Usually, fully insured plans, like plans from state health plan exchanges, HMO plans (which may even include Medicare Advantage), and third-party administrators that are commonly used for employer sponsored self-funded plans are all governed to some degree by the state Department of Insurance. State Medicaid agencies typically manage Medicaid managed care plans. CMS manages complaints surrounding Medicare Advantage plans. Once you’ve identified the type of health plan involved, locate contact information to inquire about the complaint process. This may involve a complaint that the health plan professional with whom a physician advisor has spoken does not have the requisite licensure or expertise in the services at issue as required by state or federal health plan rules. It may also involve informing the applicable agency that the health plan refuses to provide sufficient information to confirm that the denial of a member’s with applicable requirements. Often, the refusal to provide information on licensure or expertise may be coupled with a complaint of non-compliance with other rules for making coverage determinations, such as the two-midnight rule. When communicating a complaint surrounding the underlying denial, consider adding a concern that you are unable to validate that the health plan’s decision-maker has the appropriate expertise to render the adverse determination in compliance with applicable rules, due to the individual’s refusal to identify themselves.
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