Opinion ID: 2981044
Heading Depth: 2
Heading Rank: 1

Heading: The Medical-Claims Review Process

Text: Surgical removal is the only treatment for cataracts. Because prison doctors cannot authorize or perform cataract surgery themselves, doctors seeking surgery for their patients must submit a request for off-site “specialty care.” Doctors submit these requests to a “network provider,” in this case, Correctional Medical Services, Inc. (“CMS”), a private health-management company hired by the State of Michigan to screen requests against approved Michigan Department of Corrections criteria. -2- No. 10-2089 Cobbs v. Pramstaller, et al. Once a doctor submits a request, CMS will either (1) approve, (2) deny, or (3) “pend” the request. “Pending” a request suspends the decision while CMS awaits supplemental information from the requesting doctor. Only supervising physicians at CMS can deny requests. If CMS denies a request and a doctor disagrees with the denial, he may appeal to the MDOC regional medical officer. The duty of initiating the appeals process belongs to the disagreeing physician. After a doctor appeals, an MDOC regional officer ensures the completeness of the prisoner’s medical file and forwards the case to the chief medical officer—in this case, Pramstaller. The usual prison-medical-request protocol proceeds as follows: Pramstaller receives the request and medical file, which he presents for a decision at the Medical Committee’s next monthly meeting. In addition to Pramstaller, the Medical Committee includes four MDOC Regional Medical Directors, [and] a couple of physicians from the Department of Community Health that were psychiatrists. . . . And there was the state-wide CMS Medical Director, the CMS Medical Director for Utilization Review, and . . . an Associate CMS Medical Director. This team of physicians reviews doctors’ appeals and attempts to reach a consensus on whether to approve the requested treatment. If the committee cannot reach a consensus, Pramstaller holds the ultimate authority to approve requests. After deciding, the committee provides a memorandum explaining its decision to the appealing physician. An invitation to resubmit requests if circumstances change or more information becomes available accompanies each denial.