Independent medical review of health plan coverage denials: early trends.
Concerns among patients and physicians that health plans would deny coverage for medically necessary services has brought about legislation mandating independent medical review (IMR) of denied services. Among 1,400 cases submitted in California, the most common areas for dispute were cancer care, endocrine/metabolic care (especially for obesity), orthopedic care, and neurological disorders. Surgery and pharmacy services constituted 52 percent of cases. In 58 percent of cases, IMR upheld the health plan's decision, while in 33 percent of cases the health plan's decision was overturned, which suggests that external IMR provides additional patient protection in California's health care system.
Chuang
Kenneth H
KH
San Francisco VA Medical Center, San Francisco, CA, USA. Kenneth.chuang@med.va.gov
Aubry
Wade M
WM
Dudley
R Adams
RA
D002140:California; D006279:Health Maintenance Organizations / Q000458:organization & administration*; D007345:Insurance Claim Review / Q000331:legislation & jurisprudence*; D007349:Insurance, Health, Reimbursement