The Office of Patient Protection, established last year by the Massachusetts legislature, is a hit. Calls from health plan participants who have a beefor at least an unanswered questionhave been coming in at the rate of one an hour. That's twice the level of calls made to the ombudsman who had previously held the job of intervening on behalf of patients.
The new OPP has some powers that the ombudsman did notsuch as sending disputed claims to an independent outside reviewer, a doctor who specializes in the subject matter of the disputebut that's not the main reason for the increased volume. OPP director Karen Granoff says that news coverage of the legislative debate over managed care regulation "has increased awareness." Also, under the terms of the new law, every insurer had to send every enrollee a notice about the OPP.
Basically, the OPP is taking on the role that HR departments play in big companies, which, since they are usually self-insured and exempt from state regulation, are not covered by the new agency. "It's really helping walk people through the process," Granoff explains. Often that's helping them know whether it pays for them to appeal a decision and, if so, how to use the plan's internal review mechanism. But at times it means exercising clout that the individual patient cannot.
Granoff points to one case she handled: a woman whose request for reimbursement for a vaccine had been turned down. It was clearly medically necessary, Granoff says, but not until she called the plans' corporate headquarters did someone take a careful look at the case and realize that, in her words, "it was an administrative screw-up." The boss ordered a reimbursement check sent out immediately.
In another case, OPP got the patient's doctor to explain why he had ordered a nonformulary drug: The patient was allergic to an ingredient in the medication the HMO preferred, but no one had spelled that out for the plan's reviewers.
About 5 percent of the calls to OPP go to outside reviewers, for which the patient pays a $25 fee and the plan pays the restabout $400. Too few had been decided at the time of this reporting to see how often the plan's refusal to pay is valid, but a pattern of disputes had been emerging: Most cases sent to an independent reviewer center on whether a procedure is cosmetic (and therefore not covered) or whether a visit to an out-of-network providerespecially an out-of-network mental health providerare justified.
Daniel Moskowitz. Massachusetts' patient protection program on a roll. Business and Health 2001;6:17.