Agenda: Workgroup to Study the Rise in Adverse Decisions in the State Health Care System Meeting Five
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Agenda: Workgroup to Study the Rise in Adverse Decisions in the State Health Care System Meeting Five
Welcome - Senator Pamela Beidle, Workgroup Chair (5 minutes)
Presentation by the Maryland Community Health System Association about Federally Qualified Health Systems - Salliann Alborn, Chief Executive Officer, Maryland Community Health System
Presentation Organized by the Maryland State Medical Society (MedChi) - Ashton DeLong, General Counsel, MediChi and Dr. Jonathan Rubenstein, Chesapeake Urology
Questions for Group Discussion - Marie Grant, Insurance Commissioner
Question 1: Considering the current and future categories of service that carriers are required to submit to the MIA in the quarterly appeals and grievance reports, are there any gaps in the reported categories of service based on your experiences?
Background: The MIA’s 2024 Health Care Appeals & Grievance Law included data on the following categories of service: Inpatient Hospital Services; Emergency Room Services; Mental Health Services; Physician Services; Laboratory, Radiology Services; Pharmacy Services; PT, OT, ST Services (including inpatient rehab); Skilled Nursing Facility Services; Durable Medical Equipment Services (DME); Dental; Home Health Services; Obesity, IVF, Podiatry, and Hearing & Vision.
The 2025 report, which is scheduled to be published in December, 2026, was expanded to include: Adverse Decisions regarding Prior Authorization or Step Therapy Protocol; Adverse Decisions Overturned after a Reconsideration Request; Non-formulary Prescription Drugs - Number of Request made and granted; Adverse Decisions Aggregated by Zipcode; and Grievance Decisions Aggregated by Zipcode and Adverse Decisions Use of Artificial Intelligence. (Carrier Reporting Form on the MIA’s Quarterly Report by Carrier for Adverse and Grievance Decisions website as of 6/29/2026)
The 2026 report, which is scheduled to be published in December, 2027, will be further expanded include the following categories: Post-Acute Services - Skilled Nursing Facilities); Post-Acute Services - Inpatient Rehabilitation Facilities; Post-Acute Services - Inpatient Mental and Behavioral Health Treatment Services; and Post-Acute Services - Inpatient Substance Use Treatment Services.
Question 2: In light of the new regs proposed by the MHCC (Proposed Regulations under COMAR 10.25.06 - Maryland Medical Care Data Base and Data Collection), how should the different types of adverse decisions be categorized? This could include duplicate claims, eligibility issues, out of network claims, and other procedural issues that have nothing to do with prior authorization, medical necessity, or non-compliance with state mandated benefits.
Question 3: Should there be a standardized form that providers and/or consumers can use to file an appeal to an issuer? Who should create that form? Where should issuers be required to provide that form? In what method should consumers/providers be allowed to submit that form? All of these same questions could be asked about submitted prior authorizations.
Question 4: The MIA has regulatory authority over - and only receives appeals and grievance data for - commercial and fully-insured health benefit plans in Maryland. Where are there currently gaps within the commercial and fully-insured health plans, and between health plans regulated by other state agencies?
Comments from Public Stakeholders (as time allows)
- Closing Remarks
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