Appealing work

Patient protection is an oft-forgotten piece of the Affordable Care Act, even though the two-word phrase makes up the first part of the law's official name.

The controversial Patient Protection and Affordable Care Act of 2010 - in addition to making sweeping changes in the world of health insurance - also gave patients the right to ask their health plans to reconsider decisions to deny payments for medical care.

If a health plan sticks with its original decision not to pay, the patient can make a second appeal. The claim then goes to an independent third-party reviewer, according to the Centers for Medicare and Medicaid Services.

Independent reviewers have been poring over disputed medical claims since at least the late 1970s, according to the National Association of Independent Review Organizations, or NAIRO, the organization that accredits them. But demand for the reviewers is growing today as a result of changing state and federal laws, the association said. The ACA, for example, requires health plans to contract with at least three independent review organizations, according to CMS.

More than 30 accredited independent reviewers operate around the U.S. One of the newest, hoping to take advantage of rising demand, recently launched in Harrisburg.

A newcomer

Christopher Place Healthcare Review earned accreditation from the association in August 2016, and opened in January at 2209 Forest Hills Drive in Lower Paxton Township, Dauphin County.

The company was founded by Dr. Brent O'Connell, who named his company after the street where he lives. His son's name also happens to be Christopher. O'Connell previously worked at Highmark Blue Cross Blue Shield in a variety of positions ranging from medical director to vice president of medical affairs.

O'Connell has three business partners - Kyle Stavinski, Gretchen Wewer and Collin Byerly - who share ownership. O'Connell is the majority owner.

Christopher Place also employs two medical directors who oversee the firm's contracts with between 160 and 170 physicians and specialists from around the country. Those physicians, who specialize in about 62 different areas, will review medical claims as they come in to Christopher Place.

The accreditation requires Christopher Place to contract with practicing physicians who are not employees of the organization. That helps to guarantee the reviewers' independence, O'Connell said.

Christopher Place will review medical claims, either before or after service is provided, to determine if it is medically necessary. It also can review items such as billing and coding disputes, and whether doctors are ordering too many services.

Christopher Place has one contract so far with a large Blue Cross health plan, and it is in negotions with four other Blue Cross health plans in the U.S. Christopher Place is focusing on the health insurance franchise because of O'Connell's extensive knowledge of how it works.

Research and his more than 15 years in the insurance industry give O'Connell confidence his company will be successful. He has invested nearly $300,000 in its launch, he said.

O'Connell estimated that there are about 400 appeals per month for every 1 million lives covered under a health plan. The number can vary by plan, he said.

But as managed care becomes more widespread in the health care industry, more patients are appealing health plan decisions, according to a white paper by NAIRO titled "Understanding the Vital Role of Independent Review and Utilization Review Services."

Most appeals arise when health plans deny or limit coverage based on judgments that care was not medically necessary or appropriate, the paper said.

Valuing independence

Vibra Health Plan, based in Lower Paxton Township, Dauphin County, is in its first year selling Medicare Advantage plans in the state. It has found value in independent review organizations, especially as a smaller insurance company.

Smaller carriers don't have the same army of specialists as larger insurers, said Josh Bennett, Vibra's chief medical officer.

Bennett is the only medical director on Vibra's staff. Once he determines whether a claim was medically necessary, he can't review it a second time. Instead, Vibra sends the claim to a third-party reviewer. He spoke before Vibra's purchase by Capital Blue Cross.

At York-based WellSpan Health, staff there only recently became aware that they could turn an appealed claim over to an independent review organization, according to Wendy Trout, director of corporate compliance at WellSpan.

Although WellSpan rarely fights insurance companies over their decisions, it has contracts with insurers that spell out what independent review agencies can be used if the health system does.

"It's a nice option for us, because you know if the payer is reviewing their own people's work, you're not going to get a different answer," Trout said.