Insight Matters
Summer, 2004

Cleveland chapter shares concerns with insurance commissioner
by Jonathan E. Dunn, M.D., APA Representative and Cleveland Chapter Member

The Cleveland Psychiatric Society, led by President Brooke Wolf, M.D., met with the State of Ohio Insurance Commissioner, Ann Womer-Benjamin, on July 28, 2004. Issues addressed included the failure of insurance companies to publish medical necessity criteria, threats to providers that any level of review of inpatient service denials risks retroactive denial of hospital days already approved, risks of recriminatory expulsion of providers from provider panels, etc. Commissioner Womer-Benjamin said the Ohio Insurance Commission had never received any complaints on these subjects! She also made the point that certain problems require statutory relief, while others were issues of contracts between hospitals and insurance companies. It was her opinion, for example, that the denial of days when a patient refuses medication is most likely an issue involving the contract between a given insurance company and the hospital. Thus psychiatrists who find themselves in this situation need to work with their hospital administrators, instead of wasting energy getting angry at insurance company reviewers. Commissioner Womer-Benjamin said that specific complaints need to be filed and external reviews need to be requested. She seemed to be surprised that days could be taken away if a higher level of review was requested. She told us that the Insurance Commission could carry out "Market Conduct Exams" in response to specific complaints if a given insurance company is not following their stated criteria. "Market Conduct Exams" can result in fines and other appropriate action. She also requested that any examples of retribution be given to her. She would be especially interested in any written evidence of such retribution. She also recommended that we talk to the "employer community" about our concerns. She and her staff agreed to meet with us again. Commissioner Womer-Benjamin agreed, in principle to give a presentation on these issues to an upcoming meeting of the Cleveland Psychiatric Society.
One critical take home message from this meeting is that any denial of inpatient psychiatric days needs to be analyzed through 3 different optics to delineate possible remedies. Is the problem in 1)the contract between the hospital and the insurance the insurance company; 2) inappropriate actions on the part of the insurance company that might have a regulatory solution through the Office of the Insurance Commissioner; or 3) a statutory problem that requires a legislative solution (such as parity)?

OPA MEMBERS: Please follow Commissioner Womer-Benjamin's advice and consider going for the external reviews!

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