All Items for Possible Action

Transcription

1 Consent Agenda (Patrick Cates, Board Chair) (All Items for Possible Action) Consent items will be considered together and acted on in one motion unless an item is removed to be considered separately by the Board. 3.3 Acceptance of the annual PEBP Appeals and Complaints Summary for submission to the Division of Insurance.

2 BRIAN SANDOVAL Governor DAMON HAYCOCK Executive Officer STATE OF NEVADA PUBLIC EMPLOYEES' BENEFITS PROGRAM 901 S. Stewart Street, Suite 1001 Carson City, Nevada Telephone (775) (800) Fax (775) " d, I' lfill( I MI'LOVll B[N[fII, PR()(.HAM PATRICK CATES Board Chairman January 10, 2017 Barbara Richardson, Insurance Commissioner Nevada Division of Insurance 1818 E. College Parkway, Suite 103 Carson City, NY Re: Public Employees' Benefits Program (PEBP) Complaints and Appeals Summary Report Calendar Year 2016 Dear Commissioner Richardson: In accordance with NAC , PEBP presents to the Nevada Division of Insurance its annual complaints and appeals report for calendar year As required by code, the name of the employee(s) responsible for appeals and descriptions of notification procedures and explanation of rights are listed below, followed by a narrative summary of the attached complaints and appeals log. A graph showing number of complaints and appeals received in calendar years 2015 through 2016 has been included for historical comparison. NAC (l)(a), name and title of the employee responsible for the system for resolving complaints: Nancy Spinelli, Quality Control Officer, PEBP Gillis Colgan, Appeals Coordinator, PEBP NAC (l)(b), NRS 695G.200, a description of the procedure used to notify an insured of the decision regarding his complaint: PEBP is contracted with HealthSCOPE Benefits (HSB) located in Little Rock, Arkansas, to provide third-party administration services for the Consumer Driven Health Plan (CDHP) since July 1, As PEBP' s claims administrator, HSB receives claims from physicians, dentists, laboratories, and other providers. HSB reviews the claims, and processes them in accordance with provisions located in the applicable plan year PEBP Master Plan Document. Included at the bottom of every explanation of benefits (EOB) notice sent by HSB to participants is a statement that reads:

3 Barbara Richardson, Insurance Commissioner Nevada Division of Insurance January 10, 2017 Page 2 "If you have questions about this explanation of benefits, please call Customer Service at the number on the front of this form or send a written request to Attn: Claims Inquiry, PO Box 2860, Little Rock, AR within 180 days of receipt of this explanation of benefits (unless a longer term is permitted by your plan). Please note you must designate an authorized representative to us in writing in conjunction with your appeal request. Please follow the steps below to make sure that your appeal is processed in a timely manner. Send a copy of this explanation of benefits along with any relevant additional information (e.g., benefit documents, medical records) that helps to determine if your claim is covered under the plan. Contact Customer Service if you need help or have further questions. Include: I) Your name, 2) Account number from the front of this form, 3) 10 number from the front of this form, 4) Name of the patient and relationship, and 5) "Attention: Appeals Unit" on all supporting documents. Contact Customer Service at the number on the front of this form to request access to and copies of all documents, records and other information about your claim, free of charge. If your situation is urgent, you may request an expedited appeal which will generally be conducted within 72 hours. If you believe that your situation is urgent, follow the instructions above for filing an internal appeal and also call to require a simultaneous external review if permitted by your plan. You will be notified of the final decision in a timely manner, as described in your plan materials. If we continue to deny the payment, coverage, or service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an independent third party. If you are not satisfied with the final internal review, you may be able to ask for an independent external review of our decision by your plan and any state or federal requirements. For questions about your appeal rights, this notice, or for assistance, you can contact the Employee Benefits Security Administration at EBSA (x3272). Additionally, you can contact your consumer assistance program at Attn: Office of Consumer Health Assistance, Governor' s Consumer Health Advocate, 555 East Washington Ave., #4800, Las Vegas, NV 89101, , , cha@govcha.nv.gov, This is the first step available to every participant in the three-level claims appeal process afforded by the PEBP CDHP. All participants have the right to file a Level 1 appeal when they feel a claim, in whole or in apart, has been paid or denied in a manner contrary to CDHP provisions. The written request for appeal is to be mailed to the HealthSCOPE Benefits address listed at the top of each EOB. HealthSCOPE' s decision on the Level 1 appeal is mailed to the PEBP participant in writing. If HealthSCOPE approves the appeal,

4 Barbara Richardson, Insurance Commissioner Nevada Division of Insurance January 10,2017 Page 3 they reprocess the related claim(s). In the event HealthSCOPE Benefits denies the Level I appeal, the denial letter to the participant includes instructions on how he or she may then proceed to a Level 2 appeal, if the participant deems necessary. Level 2 appeals are adjudicated by PEBP, and eventual decisions on approval or denial are sent to participants in writing. In the event a Level 2 appeal is denied, the denial letter to the participant will include instructions on how he or she may then proceed to an External Review, again as deemed necessary. External Reviews are managed by the Nevada Office of Consumer Health Assistance (OCHA). The claim appeal process that PEBP describes in its Master Plan Document is in compliance with the requirements established by the Federal Health Care Reform and Nevada Insurance Statutes in NRS 695G. Forms for completing the various levels of review have been posted on the PEBP website at Summary Narrative The PEBP 2016 Quality Control Complaints and Appeals log lists 984 complaints and 7 appeals received in calendar year 2016, categorized by vendor or program, then by type. This compares to 587 complaints and 10 appeals received the prior calendar year ]n 2016, PEBP implemented new operational procedures focused on identifying and tracking participant complaints. Overall, PEBP experienced an increase in complaints over the previous year as illustrated in the summary report bar graph. Towers Watson's One Exchange (TWO E) experienced the greatest increase in complaints with 780 compared to 409 in TWOE complaints included obsolete/incorrect reimbursement forms mailed to retirees, HRA claim reimbursement denials, and overpayment notices mailed to retirees due to late carrier disenrollment reporting. Catamaran' s contract ended June 30, 2016 with an increase of26 complaints compared to the first six months of Express Script's experienced 112 complaints from July 1- December 31,2016 due to the implementation of new pharmacy benefit services for the Consumer Driven Health Plan. The percentage of complaints for PEBP, HealthSCOPE Benefits, Hometown Health Utilization Management, PPO network, HMO vendors, and Standard Insurance experienced slight to no changes in 2016 as compared to those in ]f you have any questions or comments, please do not hesitate to contact me. Sincerely, ~-~rt~ji, C~ ~ al; ~ e11f Quality Control Officer Public Employees' Benefits Program nspinelli@peb.state.nv.us

5 I. 2nd Level Appeals - PPO Plan Dental maximum % PPO Plan exclusion % Medically unnecessary 0 0.0% Total % 9 II. External Review Appeals Pre-cert denied % Total % 1 III. Complaints -HealthSCOPE Claim processing issue % Accuracy of customer service information % Coordination of benefits % Wellness % Claim accumulators not correct % Subrogation Waiver Process % HSA/HRA/FSA issues % Dental Benefits % Total % 53 1 of 6

6 IV. Complaints - Hometown Health HMO Provider not in HMO network % HMO, extent of available benefits % Accuracy of customer service information % Total % 3 V. Complaints - Hometown Health UM/CM Precertification denial % Precertification delay % Total % 4 VI. Complaints - Health Plan of Nevada HMO Extent of available benefits % Quality of providers % Total % 5 2 of 6

7 VII. Complaints - Catamaran thru 6/30/16 Mail Order % Prior authorization process % Benefits % Complaint % Trouble Shooting % Customer Service % Increased Cost % Total % 21 VIII. Complaints - ExpressScripts beginning 7/1/16 Mail Order % Prior authorization process % Benefits % Complaint % Customer Service % Increased Cost % Total % 0 IX. Complaints - Aetna Network Total 0 0.0% 0 3 of 6

8 X. Complaints - PEBP Extent of available benefits 1 1 % of Total 2015 Coordination of Benefits % Enrollment in DM % Total % 32 XI. Complaints - SHO/HHP (PPO Statewide Network) Total 0 0.0% 7 0 XII. Complaints - Standard Insurance Total 0 0.0% 0 4 of 6

9 XIII. Complaints - First Health (PPO National Network) Total 0 0.0% 0 XIV. Complaints - One Exchange Enrollment Issues % HRA Funding Reimbursement % Policy Carrier issues % Customer Service % Phone wait time % Total % 409 Summary Report Totals Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 YTD Total 2015 Grand Totals of 6

10 PEBP 2016 Complaints/Appeals Summary Report 0.6% 2nd Level Appeals - PPO Plan 0.1% External Review Appeals 2.6% HealthSCOPE 1.0% Hometown Health HMO 0.3% Hometown UM/CM 0.2% Health Plan of NV 4.7% Catamaran 11.3% Express Scripts 0.4% PEBP 0.0% AETNA Network 0.0% SHO/HHP (PPO Statewide) 0.0% The Standard 0.0% First Health (PPO National) One Exchange 78.7% 0% 10% 20% 30% 40% 50% 60% 70% Percentage As Measured Against All Complaints/Appeals Received 6 of 6