Appeals

The proposed new standard, HCP 5, establishes minimum requirements for the due process that must be allowed to providers who choose to appeal an organization's performance measurement.  It reads:

If the physician or other provider makes an appeal within 30 days of receiving notice from the organization, then no change will be made to the information or ranking and it will remain unpublished until such time as the dispute is resolved. [4]

By requiring the health plan or health network to resolve a timely-filed provider appeal before it can implement a performance measurement publication or use in tiering, this standard places a premium on handling appeals promptly.  Think of it this way -- if you publish or use in network tiering a new or newly revised performance measurement system when there is an outstanding appeal that was timely filed, you have violated this standard.

This suggests what will be useful information for reviewers.  Certainly, at the AccreditNet phase you'll need to submit a P&P that mirrors the standard.  The onsite review likely will look like a two-fold request -- one for the a list of the dates of any launch or revision to your performance measurement system and the other for a list of provider appeals.  The reviewer will then cross check the two lists, looking for publication before appeal resolution.

HCP 4, a proposed new standard, would read:

The organization shall have a reasonable, prompt, and transparent appeals process to address physician and provider performance measurement issues that provides: [4]
(a) A written response back to the physician or other provider regarding the outcome of the appeal that includes: [--]
(i) A reason for the appeal decision; and [4]
(ii) An indication of the next actions that the organization will take as a result of the appeal decision. [4]

This standard creates an appeal mechanism for providers who are aggrieved by an organization's performance measurement with the right to appeal. That right includes a right to a written response that explains the decision on appeal and what response, if any, the organization has to the appeal.

Documentation requirements at the AccreditNet phase of the application process, while not yet published, are likely to be the submission of a policy and procedure describing the appeal mechanism. The onsite review process is likely to involve providing the reviewer with a list of all appeals submitted, from which the reviewer will select a sample in order to look at the documentation of the appeal, and particularly the written response to the provider.

Because this standard has a couple of technical issues with it, I today submitted the following comment to URAC about this standard:

First, I'd like to make a comment that applies to all the HCP standards. "Physicians" are a subset of "provider", so all references to "physicians and other providers" or, as in the case of HCP 4, "physicians and providers", offer superfluous language. "Provider" should suffice.

Second, a basic rule of outlining is to not create numbered or lettered lists out of only one item. In this case, the standard has an "(a)" without a "(b)".

I recommend, therefore, that this standard read as follows:

The organization shall have a reasonable, prompt, and transparent appeals process to address provider performance measurement issues that provides a written response back to the provider regarding the outcome of the appeal that includes: [4]

(a) The reason for the appeal decision; and [4]

(b) An indication of the next actions that the organization will take as a result of the appeal decision. [4]

The v. 4.1 upgrade to WC UM 34 is a partner to the revision to WC UM 33 (see blog on that standard here). Like the WC UM 33 revision, this is billed as a "clarification of intent" standard. Also like the UM 33 revision, it is a significant clarification.

The 4.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?" But then, one would have thought that WC UM 35 answered the question. That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?

URAC sorts it all out in the v. 4.1 WC UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

The v. 4.1 "upgrade" for WC UM 33 is billed as a "clarification of intent", which sounds minor. However, for some applicants, the "clarification" could be a bigger deal than might be suggested.

The standard's purpose is to establish a time frame for notification of the patient and provider in the event of expedited appeals. The previous version (v. 4.0) read:

Expedited appeals are completed with verbal notification of determination within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days. (Primary)

What is unclear about this is to whom each of these two notifications, verbal within 72 hours and written within 3 days, must go. Version 4.1 clears that up:

Expedited appeals are completed with verbal notification of determination to the requesting party within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

So, the 72-hour verbal notice need go only to the requesting party, whether it be the provider or the patient. Only the written notification needs to go to both the consumer and the provider. This surely will be a relief to those URAC applicants that were playing it safe and giving verbal notice to everybody in the first 72 hours.

Playing it safe with a standard like this is not a bad strategy: you don't mess around with mandatory standards.

The v. 5.1 upgrade to UM 34 is a partner to the revision to UM 33 (see blog on that standard here).  Like the UM 33 revision, this is billed as a "clarification of intent" standard.  Also like the UM 33 revision, it is a significant clarification.

The 5.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?"  But then, one would have thought that UM 35 answered the question.  That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?  

URAC sorts it all out in the v. 5.1 UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

The v. 5.1 "upgrade" for UM 33 is billed as a "clarification of intent", which sounds minor.  However, for some applicants, the "clarification" could be a bigger deal than might be suggested. 

The standard's purpose is to establish a time frame for notification of the patient and provider in the event of expedited appeals.  The previous version (v. 5.0) read:

Expedited appeals are completed with verbal notification of determination within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days. (Primary)

What is unclear about this is to whom each of these two notifications, verbal within 72 hours and written within 3 days, must go.  Version 5.1 clears that up:

Expedited appeals are completed with verbal notification of determination to the requesting party within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days to the patient and attending physician or other ordering provider or facility rendering service.  (Primary)

So, the 72-hour verbal notice need go only to the requesting party, whether it be the provider or the patient.  Only the written notification needs to go to both the consumer and the provider.  This surely will be a relief to those URAC applicants that were playing it safe and giving verbal notice to everybody in the first 72 hours.

Playing it safe with a standard like this is not a bad strategy: you don't mess around with mandatory standards. 

Are your policies and procedures describing your non-certification appeals process available upon request to any patient, provider, or facility rendering service?

If you answer "yes" to this question, you're only partly on your way to meeting the requirements of URAC Health Utilization Management standard 30. One more question to go:

Does your P&P say that it's available to any consumer, provider, or facility?

If you say "no" to this question, it's time to revise your policy.

HUM 30 provides, in relevant part, that:

The organization maintains a formal process to consider appeals of non-certifications that includes:

* * *
(b) Written policies and procedures that:

* * *
(iii) Are available, upon request, to any patient, provider, or facility rendering service. (Primary)

Remember, in the world of URAC (or any other accreditation program), if it isn't documented, it isn't happening. So, it is not merely enough that you P&P is available, but it must say that it's available. And, you must submit this documentation with your application in order to avoid getting a comment from your reviewer asking for more documentation.

One more thing: This is a primary element of a mandatory standard, so failure to provide this documentation could cost you the full accreditation you're hoping to earn.

In what some veteran reviewers might see as a change in interpretation, it appears that URAC is now including employees in what has previously been seen as a standard designed to protect only consumers.

Core 27 reads:

"The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal."

Historically, URAC reviewers have read this as referring to consumers, which URAC defines as "An individual person who is the direct or indirect recipient of he services of the organization. Depending on the context,consumers may be identified by different names, such as "member,” enrollee,” “beneficiary,” “patient,” “injured worker,”“claimant,” etc."

Note, however, that "employee" isn't one of the suggested synonyms for "consumer."

So, imagine my surprise when I learned that at least one URAC reviewer is now reading this standard more broadly, saying that, despite the fact that an applicant is describing its member and client appeals system thoroughly enough, its submission is insufficient, in that it does not explain how employees and the community (including "office neighbors, parking or grounds attendants") can file a complaint.

Let there be no mistake -- this is no complaint. I have nothing vested in a particular interpretation of a URAC standard. If URAC wants to expand the scope of this standard to include employees and community members, more power to it. I provide this here simply to alert our readers that their submission for this standard is likely to be insufficient if it includes only a description of its complaints and appeals system for consumers and clients.

One set of URAC's Core standards, Core 27-29, spell out requirements for complaints and appeals. They provide:

CORE - 26 - Complaint and Appeal System
The organization maintains a system to receive and respond in a timely manner to complaints and, when appropriate, inform consumers of their rights to submit an appeal.
CORE - 27 - Appeal Process
The organization maintains a formal appeal resolution process that includes:
(a) Written notice of final determination with an explanation of the reason for the determination;
(b) Notification of the process for seeking further review, if available; and
(c) A reasonable, specified time frame for resolution and response.
CORE - 28 - Complaint and Appeal Reporting
The organization reports analysis of the complaints and appeals to the quality management committee.

The question I get most often from my clients about these standards is this: "Does this create appeal rights for all complaints?"

The answer is, "no". The standards are careful to use the phrases "if available" and "when appropriate" when referring to appeal rights. Other URAC standards do grant very specific appeal rights, but not these.

No, these standards simply explain that you must have a system for responding promptly to all complaints, and where you do offer appeal rights, that it be formal, including written notice of final determination, notification of the process for appeal, and reasonable time for resolution. And, don't forget to report periodically to the quality committee!

If you say you have no complaints, URAC's view, articulated at a recent education seminar, is that your employees probably don't know what a complaint is.  URAC's definition is broad: "An expression of dissatisfaction regarding the organization’s products or services."  With a definition that broad, URAC's thinking goes, you should have some complaints in your tracking system.