Independent medical review of health plan coverage denials: Early trends

Kenneth H. Chuang, Wade M. Aubry, R. Adams Dudley

Research output: Contribution to journalReview articlepeer-review

5 Scopus citations

Abstract

Concerns among patients and physicians that health plans would deny coverage for medically necessary services has brought about legislation mandating independent medical review (IMR) of denied services. Among 1,400 cases submitted in California, the most common areas for dispute were cancer care, endocrine/metabolic care (especially for obesity), orthopedic care, and neurological disorders. Surgery and pharmacy services constituted 52 percent of cases. In 58 percent of cases, IMR upheld the health plan's decision, while in 33 percent of cases the health plan's decision was overturned, which suggests that external IMR provides additional patient protection in California's health care system.

Original languageEnglish (US)
Pages (from-to)163-169
Number of pages7
JournalHealth Affairs
Volume23
Issue number6
DOIs
StatePublished - Nov 2004
Externally publishedYes

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