Emergency Room for Not Applicable: 53.8% of denials overturned
In 13 California IMR decisions from 2009 to 2017, reviewers overturned 7 (53.8%). , 13 urgent care.
What the findings mention
| What the findings mention | Decisions | Overturned | All decisions here |
|---|---|---|---|
| Urgent or emergencyThe findings mention urgency. | 13 | 53.8% | 53.8% |
Keyword matches on the reviewer’s findings, not causes. A tag that appears mostly in overturned decisions is worth documenting in an appeal; it is not a guarantee.
From recent overturned decisions
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the …”
“Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested emergency medical services for the dates of service in question (including the services rendered by San Diego Imaging Medical Group, Rady Children’s Hospital, and Sharp Coronado Hospital). Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the …”
“Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services provided on an emergent basis or urgent basis. Findings: The physician reviewer found that the issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation …”
And one the reviewer upheld
“A 38-year-old female enrollee has requested emergency services for treatment of her rash. Findings: The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. In this case, the patient presented ambulatory with a pruritic rash for several days. The patient reported to …”
- California only: these are decisions by independent reviewers under California's IMR program (plans regulated by the Department of Managed Health Care). Other states and self-funded employer plans use different reviewers and rules.
- Selection: only denials that a member took all the way to IMR appear. Most denials are never appealed, and the ones that reach an external reviewer are not a random sample.
- Overturned means the reviewer disagreed with the plan; it does not mean the treatment worked or that a similar request will be approved.
- Argument tags are keyword matches on the reviewer's findings. They describe what the findings mention, not why the case was decided.
- Categories are DMHC's own labels (treatment sub-category and diagnosis category); 'Other' is a catch-all and is excluded from rankings.
Source: California Department of Managed Health Care, Independent Medical Review (IMR) Determinations, Trend (CHHS Open Data). Public California government data; Apellica's aggregates and tags are CC BY 4.0.
Questions
How often were Emergency Room denials for Not Applicable overturned?
In 13 California IMR decisions from 2009 to 2017, reviewers overturned 7 (53.8%). , 13 urgent care.
What should an appeal document, based on these findings?
Whatever the plan's criteria ask for, shown in the record: the treatments already tried and their results, contraindications to the plan's preferred option, the guideline or evidence that supports the request, and the treating clinician's reasoning written to the criteria. The tag table shows which of these the reviewers mentioned most in overturned cases.
Does a California IMR result apply to my plan?
Only California plans regulated by the Department of Managed Health Care go to IMR. Other states and self-funded employer plans use different reviewers, but they weigh the same things.
Independent reviewers reverse plans when the record answers the criteria. Upload the denial letter; a senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.