What is the name of your state? NY
I just got off the phone with the AG's office. Maybe someone can help me understand what the atty said, because it doesn't make sense to me?
I assumed that my HMO was in review violation, because the "reason and clinical rationale" that my HMO gave me for medically unnecessary, while correct, had nothing to do with the HMO determined guidelines. As in, where the HMO writes "sinus surgery will be covered if the following guidelines are matched." No reason was given, per the guidelines. The AG atty told me that the UR law requires the HMO to state clinical rationale. That the UR law does not specify that the reasons and the clinical rationale, must be based on the hmo determined guidelines. Basically, any clinical contrary evidence is meeting the UR definition of reasons and clinical rationale.
That sounds crazy to me. If true, what's the point of the HMO guidelines?
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A guideline is just that - a guide. It is neither law nor cast in stone.
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I don't mean to beat a dead horse. I'm just confused how the UR fits the guidelines into the "clinical review criteria." I found the ARTICLE 49 UTILIZATION REVIEW Section 4900. Definitions, (I'm quoting all of (j), because I don't want to take the text out on context) (3) is what confuses me:
(j) "Utilization review plan" means: (1) a description of theprocess for developing the written clinical review criteria; (2) a description of the types of written clinical information which the plan might consider in its clinical review, including but not limited to, a set of specific written clinical review criteria; (3) a description of practice guidelines and standards used by a utilization review agent in carrying out a determination of medical necessity; (4) the procedures for scheduled review and evaluation of the written clinical review criteria; and (5) a description of the qualifications and experience of the health care professionals who developed the criteria, who are responsible for periodic evaluation of the criteria and of the health care professionals or others who use the written clinical review criteria in the process of utilization review.
I understand (3) to mean that my HMO had to create their own guidlines for a procedure/treatment for their utilization review agent in carrying out a determination of basic necessity. So wouldn't the HMO have to abide the guidelines, like a contractual agreement?
If so, and this is really confusing to me:
My HMO's Clinical information required for Medical Director review:
* CPT codes to be performed
* Office Notes
* Radiographic and CT scan reports
* Photographs, if requested, in cases of nasal trauma or nasal valve collapse
my adverse determination cites that my CT scan failed to show sinus disease. But My HMO clearly states that:
Ethmoidectomy, Maxillary Entrostomy, Frontal Sinusotomy & Sphenoid Sinusotomy
Surgery will be covered if the following clinical guidelines are met:
* Treatment for sinusitis and/or respiratory symptoms should have been rendered within the past year AND
* 3 or more office visits with the diagnosis of sinusitis AND
* 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
* Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
* An acute respiratory infection unresponsive to initial antibiotic therapy of 24-48 hours OR
* A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis
I meet and document (doctors note's, MRI films, receipts, etc.) the first four criteria. The CT scan at issue, is a requirement for Medical Director review, but what the CT scan reports is not a requirement for the first four guidelines. Maybe I'm just dunce, but I don't understand why my HMO hasn't committed a UR violation? If anyone can explain, I'd really appreciate it.
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I don't mean to beat a dead horse. I'm just confused how the UR fits the guidelines into the "clinical review criteria." I found the ARTICLE 49 UTILIZATION REVIEW Section 4900. Definitions, (I'm quoting all of (j), because I don't want to take the text out on context) (3) is what confuses me:
(j) "Utilization review plan" means: (1) a description of theprocess for developing the written clinical review criteria; (2) a description of the types of written clinical information which the plan might consider in its clinical review, including but not limited to, a set of specific written clinical review criteria; (3) a description of practice guidelines and standards used by a utilization review agent in carrying out a determination of medical necessity; (4) the procedures for scheduled review and evaluation of the written clinical review criteria; and (5) a description of the qualifications and experience of the health care professionals who developed the criteria, who are responsible for periodic evaluation of the criteria and of the health care professionals or others who use the written clinical review criteria in the process of utilization review.
I understand (3) to mean that my HMO had to create their own guidlines for a procedure/treatment for their utilization review agent in carrying out a determination of basic necessity. So wouldn't the HMO have to abide the guidelines, like a contractual agreement?
If so, and this is really confusing to me:
My HMO's Clinical information required for Medical Director review:
* CPT codes to be performed
* Office Notes
* Radiographic and CT scan reports
* Photographs, if requested, in cases of nasal trauma or nasal valve collapse
my adverse determination cites that my CT scan failed to show sinus disease. But My HMO clearly states that:
Ethmoidectomy, Maxillary Entrostomy, Frontal Sinusotomy & Sphenoid Sinusotomy
Surgery will be covered if the following clinical guidelines are met:
* Treatment for sinusitis and/or respiratory symptoms should have been rendered within the past year AND
* 3 or more office visits with the diagnosis of sinusitis AND
* 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
* Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
* An acute respiratory infection unresponsive to initial antibiotic therapy of 24-48 hours OR
* A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis
I meet and document (doctors note's, MRI films, receipts, etc.) the first four criteria. The CT scan at issue, is a requirement for Medical Director review, but what the CT scan reports is not a requirement for the first four guidelines. Maybe I'm just dunce, but I don't understand why my HMO hasn't committed a UR violation? If anyone can explain, I'd really appreciate it.
Very simply..it is possible they are denying your surgery because your CT scan is negative which, clinically speaking, means there is NO sinusitis.
I understand this determination is in spite of other Physician's diagnosis and treatment, but the HMO obviously doesn't care about that. That seemingly small part of the overall picture (CT results) is all it takes for the UR "red light" to pop up. It's their medical director's job to make the determination based upon that particular HMO's UR guidelines, and it looks like h/she did. You met 4 of the 5 criteria...not ALL of the criteria.
Like I suggested in your earlier post, when open season comes up (and I believe it's almost here) perhaps you can switch to a PPO.
Hope this explanation helps. Good luck to you.
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Switching to a PPO won't change the UR requirements. The difference between a PPO and HMO just has to do with freedom to choose your doctor. In an HMO, you have a primary care physician who must be in your network, and in order to see most kinds of specialists, you need a referral from the PCP. The specialist also must be in the network. No out of network benefits are possible in an HMO except in the case of emergencies, though sometimes exceptions can be made if no in-network specialists are available in the area.
In a PPO, you have one level of benefits for using in-network doctors and another, lower level for out of network doctors. It is not required that you declare your PCP to your insurance and you do not need referrals to see specialists. However UR would still be required for non-emergency surgeries and inpatient admissions.
"Open access" HMO's have recently become available that do not require referrals, but also do not have out of network benefits. There are also plans that work like HMO's(requiring referrals), but also offer a lower level of benefits for out of network doctors. When I worked at Aetna we called those Point Of Service plans, but I don't know if that's an industry-wide term or not.
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Switching to a PPO won't change the UR requirements. The difference between a PPO and HMO just has to do with freedom to choose your doctor. In an HMO, you have a primary care physician who must be in your network, and in order to see most kinds of specialists, you need a referral from the PCP. The specialist also must be in the network. No out of network benefits are possible in an HMO except in the case of emergencies, though sometimes exceptions can be made if no in-network specialists are available in the area.
In a PPO, you have one level of benefits for using in-network doctors and another, lower level for out of network doctors. It is not required that you declare your PCP to your insurance and you do not need referrals to see specialists. However UR would still be required for non-emergency surgeries and inpatient admissions.
"Open access" HMO's have recently become available that do not require referrals, but also do not have out of network benefits. There are also plans that work like HMO's(requiring referrals), but also offer a lower level of benefits for out of network doctors. When I worked at Aetna we called those Point Of Service plans, but I don't know if that's an industry-wide term or not.
Pretty much all the insurances available down here have a POS option. I understand what you're saying about PPO vs HMO, but none of us can recall a patient having to jump through so many hoops when they're on a PPO.
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Very simply..it is possible they are denying your surgery because your CT scan is negative which, clinically speaking, means there is NO sinusitis.
I understand this determination is in spite of other Physician's diagnosis and treatment, but the HMO obviously doesn't care about that. That seemingly small part of the overall picture (CT results) is all it takes for the UR "red light" to pop up. It's their medical director's job to make the determination based upon that particular HMO's UR guidelines, and it looks like h/she did. You met 4 of the 5 criteria...not ALL of the criteria.
Like I suggested in your earlier post, when open season comes up (and I believe it's almost here) perhaps you can switch to a PPO.
Hope this explanation helps. Good luck to you. I'm not sure if you caught the "or" in the criteria? The first three guidelines were required and then the member has a "choice" of one of the last three. I DID meet all the criteria. I just "happened" to have MRI's lying around from May and August showing significant opacification. My HMO has approved ethmoid and maxillary sinus surgery. My HMO is citing that I need to show sinusitis in a specific cavity, the frontal sinus, in order to endoscopy the frontal sinus, despite specific physical symptoms. That's why I'm confused about the guidelines. It doesn't say that I have to prove sinusitis in each cavity. The guidelines don't require a specific diagnosis from the CT scan.
Thanks, I reallu appreciate the time you took to answer.
edited to ad: I don't think that I can join a PPO. I am self-employed, and Workman's Comp exempt
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That doesn't mean you can't purchase coverage through a PPO, just that it will be more expensive.
BTW, while it is true that many employers are currently moving into the Open Enrollment season, it is by no means universal. Open Enrollment can happen at any time of year, depending on when the policy is up for renewal.
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I'm not sure if you caught the "or" in the criteria? The first three guidelines were required and then the member has a "choice" of one of the last three. I DID meet all the criteria. I just "happened" to have MRI's lying around from May and August showing significant opacification. My HMO has approved ethmoid and maxillary sinus surgery. My HMO is citing that I need to show sinusitis in a specific cavity, the frontal sinus, in order to endoscopy the frontal sinus, despite specific physical symptoms. That's why I'm confused about the guidelines. It doesn't say that I have to prove sinusitis in each cavity. The guidelines don't require a specific diagnosis from the CT scan.
Thanks, I reallu appreciate the time you took to answer.
edited to ad: I don't think that I can join a PPO. I am self-employed, and Workman's Comp exempt
First....yes you can join a PPO. I am also self employed and have a plan through a PPO, albeit with a very large deductible!.
Second...I did catch the "or" and I know it's hard to understand, because I often scratch my head regarding some decisions made by HMO Medical Directors, but they are basing their determination on the fact that your CT was "normal" and there is no evidence of sinusitis in your frontal sinus. I would have thought the letter from your Cardiologist, pointing out the cardiac risks of having 2 separate procedures, would have help.
Who knows? Perhaps they're basing their decision on the increased risk of infection from endoscopy of your frontal sinus without evidence of sinus disease. Maybe it's the cost factor alone... BUT... in their interpretation of their UR specifications, they do not seem to be in violation.
Wish I could give you better news. Good luck.