July 31, 2002
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Division Of Insurance Completes Annual Managed Care Accreditation

Review Focuses On Provider Networks and Mental Health Delivery Systems

( BOSTON, MA) The Division of Insurance today announced the accreditation effective August 1, 2002 of 49 insurance carriers that offer managed care plans in the Commonwealth. The accreditation review, begun in April, marks the second year that managed care plans must receive accreditation from the Division's Bureau of Managed Care under M.G.L. Chapter 176O. This year's process included the on-site examination of nine HMOs' mental health delivery systems, the review of coverage denial notices and the inclusion of "concierge physicians" within managed care networks.

"A great deal of time and resources were dedicated to address important health care issues that have arisen since the first accreditation was completed," said Insurance Commissioner Julie Bowler. "Based upon this review, I'm confident that the carriers will meet all of their responsibilities under the law."

Specific to the review of the nine HMOs' mental health delivery systems, the Division used nationally recognized accreditation surveyors to conduct on-site examinations of the HMOs' internal processes. "Our reviewers found that the carriers have substantially met the provisions for accreditation. Where improvement is needed, the Division met with management and Board members so that they could demonstrate to me the steps that are being taken to reach full compliance under our laws. The Division's reviewers will follow-up with these carriers to ensure that they implement the corrective action plans and internal audit controls as presented to the Division," Bowler said. The Division will produce reports summarizing the results of the on-site special examinations in September.

In addressing concerns raised by the Department of Mental Health and the Department of Public Health's Office of Patient Protection, the Division directed carriers to amend their provider directories to indicate which mental health providers treat pediatric, geriatric, substance abuse and eating disorders patients, indicate which providers would no longer accept new patients and highlight whether any providers would require a fee as a condition of being a patient's physician.

The Division also directed carriers to amend their coverage denial notices to further clarify reasons for all denials and explain rights to appeal through both internal and external systems. Each company has made the necessary amendments or submitted action plans to demonstrate how their network directories and denial notices will be amended.