West Virginia Offices of the Insurance Commissioner 2009 Annual ...

Family/General Internal General Neurology Orthopedic Pain
Chiropractor
Practice
Medicine Surgery
Management
Network 1 752 318 180 52 158 66 205
Network 2 454 170 97 36 5 18 119
Network 3 532 241 105 35 62 0 72
Network 4 638 385 129 44 109 28 103
Network 5 162 161 128 32 87 8 114
Based on the requirements of Series 85, Rule 21 managed health care plans must report semi-annually.
A system was developed to standardize the plan reporting process. In addition to the medical cost
data, these reports include information on the number of grievances filed with each managed health
care plan and a summary of the action taken. The data collected in this system is an aggregate of the
claims managed by each health care plan and experienced by multiple employers and/or carriers. The
reported data is sorted by a set of disease and injury numbers called the International Classification of
Disease (ICD) codes. The type of information collected includes the: number of employees and
injuries treated by each code; total medical costs sorted by physician, hospital, drug and others costs;
average costs per injured employee and average cost per code; along with the number of days
employees were absent from work. Due to approval dates of the plans, only seven (7) were required to
report for both periods during the 2009 calendar year. The following is an aggregate of some of the
reported data:
Aggregate Health
Plans Reporting
Period
January 1 – June 30,
2009
July 1 – December
31, 2009
# of Employees Treated
by ICD-9 Code During the
6 mo Period
Total
Medical Cost
# of Days
Absent from
Work
6,663 $ 7,771,397 114,725 432
20,648 $27,293,155 399,403 363
Grievances
Reported
A grievance reporting tool is included in the semi-annual reports that allows the approved plans to state
the results of their grievance process. Each plan may determine whether their grievance process is
mandatory or optional. These terms are further defined to mean: Mandatory MHCP grievance process
(intent of MHCP is to have a grievance process that must be exhausted before litigation); Optional
MHCP grievance process (intent of MHCP is to have a grievance process that may be exhausted
before litigation). During 2009, all but one (1) of the approved MHCP’s, reported mandatory
grievance processes.
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