INTRODUCTION
The respondents can challenge treatment recommended by the attending physician by either obtaining a Respondents' Medical Examination or, in some instances, through utilization review. The following is a summary of the four-step utilization review process that applies to medical care plans established by an employer under Connecticut General Statutes section 31-279 (c). Reg. 31-279-10 12 (e) details this utilization review process. I have included with each step a comparison with the equivalent step in the Respondents' Medical Examination process and a recommendation of what you should be doing at each stage of the UR process.
STEP 1. THE DECISION TO SEEK PEER REVIEW - The party initiating review (nearly always the respondent) shall provide to the plan all information in its possession as it deems necessary to conduct the review. The plan may also request information.
The plan must issue its written decision within two business days of receiving all of the relevant information. Any denial must include the reasons for denial and the name and phone number of the person to contact with regard to an appeal. This first level of review can be done by any health professional holding a current and valid license in a state licensing agency in the U.S. Any physicians must be licensed in Connecticut.
(Compare: The Connecticut Workers' Compensation Commission issued "Payor and Medical Provider Guidelines to Improve the Coordination of Medical Services," which provide that the respondents have twelve days from receiving all medical records to schedule a Respondents' Medical Examination (RME). Any non-healthcare professional can make this decision, although typically now a case nurse manager reviews a surgery request.)
What you should be doing......
Check to make sure that the decision is rendered within two days. If not, call the plan administrator to have the treatment authorized and list this as part of the appeal. Diary the fifteen-day appeal deadline.
STEP 2. PEER REVIEW - You must notify the plan within fifteen days of the written UR denial of your intent to appeal the determination. For purposes of reviewing the plan's initial decision, you can request "a practitioner in a specialty relating to the claimant's condition." Physicians must have a current and valid Connecticut license. The reviewing practitioner must within fifteen days submit his/her opinion to the medical director of the medical care plan, who must within fifteen days thereafter, render a written decision regarding treatment.
(Compare: RME must take place within sixty days, and twenty-one days thereafter, the report must issue. Must be a “medical provider in a same or similar specialty.”)
What you should be doing....
Immediately fax and send the following letter: "The claimant/patient in the above-referenced matter hereby appeals the plan's denial of [requested treatment]. S/he also requests that the reviewing practitioner be in a specialty relating to the condition at issue, namely [neurosurgeon, orthopedic spine specialist, etc.]."
STEP 3. HEARING BEFORE THE C.E.O. - You appeal the medical director's decision to the chief executive officer (CEO) of the medical care plan in writing within fifteen days. "The party requesting further review" can also request a hearing, which must take place within fifteen days. You can present written or oral testimony at this hearing. The chief executive officer shall issue a decision "as soon as practical" but no later than thirty days from the written request for appeal or the hearing. The CEO does not need to have medical training. Figueroa v. Rockbestos, 4633 CRB-1-03-2 (2004).
(Compare: Pre-formal hearing, followed by formal hearing or commissioner's medical examination.)
What you should be doing.....
Diary the fifteen-day appeal deadline. Fax and send the following letter to the chief executive officer: "The claimant/patient in the above-referenced matter hereby appeals the medical director's denial of [requested treatment]. S/he also requests a hearing with reasonable notice to take place within fifteen days to present written and/or oral testimony."
STEP 4. COMMISSIONER REVIEW - A commissioner can only modify the CEO's decision if it is "unreasonable, arbitrary or capricious." In other words, if it's unreasonable. The claimant can request from the commissioner a second opinion from a doctor outside the plan at the respondents' expense. Reg. 31-279-10 12. Under the regulations, this request is deemed reasonable.
(Compare: Commissioner must adhere to the opinion of the commissioner's examiner unless s/he articulates specific reasons for discrediting or deviating from the opinion.)
What you should be doing....
Request an informal hearing to seek a second medical opinion from a physician outside the network. If this doctor agrees with the treating physician, then request a formal hearing on the issue of whether the CEO's decision is reasonable. You also will want to know if the CEO serves in some other capacity in the medical plan, such as human resources director, etc., where his/her decision might be biased. See Figueroa.
