Press Release  NEW RESEARCH SHOWS INSURANCE APPEAL AND REVIEW PROCESS PROTECTS MASSACHUSETTS PATIENTS

BOSTON – Thursday, December 20, 2018 — Today, the Massachusetts Health Policy Commission (HPC) issued its ninth issue of DataPoints, examining trends in internal appeals and external reviews pursued by health insurance consumers from 2014 to 2017. This new research found that a significant number of consumers obtained coverage for medically necessary care through an internal appeal with their health plans or through the Office of Patient Protection’s (OPP) external, independent review process, highlighting the importance of these processes for consumers in the Commonwealth. The findings will be featured in OPP’s upcoming 2017 Annual Report, scheduled for release in early 2019.

The HPC identified notable trends in appeals related to behavioral health (BH) care that warrant further examination. Despite the increase in the total number of internal appeals filed between 2014 and 2017, there was a decrease in both the total number of appeals related to coverage of BH treatment, and the percentage of appeals related to BH treatment compared to medical/surgical treatment. Fewer appeals could suggest that policy changes promoting access to BH care, including mental health parity and other state and federal laws, may be favorably affecting consumers’ access to BH services. During the same time period, the HPC found that consumers who filed internal appeals with their health plan related to medical/surgical treatment received a favorable decision nearly twice as often as those consumers who filed appeals related to BH treatment.

“Protecting consumer rights and ensuring access to quality health care is a vital part of our mission to advance a more transparent and accountable health care system in Massachusetts,” said David Seltz, HPC Executive Director. “This analysis provides greater insight into how patients access health insurance coverage for necessary health care – both medical/surgical treatment, and behavioral health care.”

OPP is operated by the Health Policy Commission and is responsible for regulating and administering certain health insurance consumer protections for the Commonwealth. It is a resource for individuals who want to become more informed and empowered health care consumers.

Internal appeals, the first step for a consumer to challenge a coverage denial, are conducted by the health plan, which may uphold its initial decision or overturn its initial denial of coverage for all or part of the treatment. If the health plan upholds its denial, consumers may request an independent external review. OPP administers the external review process for Massachusetts consumers with fully-insured health plans by contracting with external review agencies that review medical records and issue final decisions. OPP also administers external reviews for accountable care organizations (ACOs) and risk-bearing provider organizations, issues open enrollment waivers, and provides information and education about health insurance concerns to the public.

Key Findings

• Since 2014, the total number of internal appeals has increased each year, and the percentage of consumers who have received a favorable outcome (i.e., coverage for treatment) from the internal appeal process increased from 44% in 2014 to 57% in 2017.
• Despite the increase in the total number of internal appeals filed between 2014 and 2017, there was a decrease in both the total number of internal appeals related to coverage of BH treatment, and the percentage of appeals related to BH treatment compared to medical/surgical treatment.
• Between 2014 and 2017, OPP received fewer eligible requests for external reviews related to BH treatment.
• Requests for external reviews related to substance use disorder (SUD) treatment consistently made up ~30% of all BH external reviews each year.
• While OPP reported a declining percentage of external reviews regarding BH treatment resolved in favor of the consumer from 2014-2016, in 2017, 59% of those external reviews were resolved in favor of the consumer, the highest percentage in the past four years.
• Unlike internal appeals, there was no consistent trend showing that consumers requesting external reviews for BH treatment were either more or less likely to receive a favorable decision than those requesting external reviews for medical/surgical treatment.

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