Health Policy Experts to Address California's Independent Medical Review Program

Two experts will discuss findings from, "A Study of California's Independent Medical Review Program," during a health policy seminar on Friday, April 13 at UCSF.

Wade Aubry, MD

Co-sponsored by the UCSF Philip R. Lee Institute for Health Policy Studies and by the UCSF/UC Hastings Consortium on Law, Science and Health Policy, the seminar is scheduled to run from 12:15 to 1:30 p.m. in Laurel Heights room 376.

Speakers are:

• Wade Aubry, MD, associate clinical professor in the Department of Medicine and the UCSF Philip R. Lee Institute for Health Policy Studies; and
• Deborah Reidy Kelch, MPPA, health policy researcher and founder of the Kelch Policy Group in Sacramento, CA.

For more than a decade, California has required health plans be regulated by the Departments of Managed Health Care and Insurance to provide consumers with the opportunity for independent external review of coverage denials through its Indpendent Medical Review (IMR) program. This important program offers individuals an expert second opinion on care that has been denied or delayed by their health plans due to medical necessity, experimental/investigational reasons or emergency or urgent medical services.

The IMR process cannot be used for an insurance company decision that is based on a coverage issue. Only decisions regarding a disputed health care service, as it relates to the practice of medicine, that do not involve a coverage issue are qualified for the IMR program.

Reidy, lead author of the aforementioned study, and Aubry, a former health plan medical director who conulted on the study and co-authored an earlier study of IMR, will present the findings of the California Health Care Foundation report, "Ten Years of California's Independent Medical Review Process: A Look Back and Prospects for Change [PDF]."

This review of the state's IMR program relies on data for all IMR cases from the program's inception through 2010 to consider the program experience and lessons learned to date as well as the implications for the expansion of external review under the federal Affordable Care Act.

The Affordable Care Act, now under review by the U.S. Supreme Court, mandates independent medical review for all coverage, including not only state-regulated health insurance products but also self-insured group plans subject primarily to federal oversight. The federal government has determined that California’s IMR program meets the federal standards.

Read more on the California Helath Care Foundation website.