Maximus Nets Nation's Largest Patient Protection Deal

Maximus Inc. of Reston, Va., announced Sept. 4 that it was awarded a contract worth up to $21.8 million to provide independent review for Medicare patients who appeal managed care denials.


The contract was awarded by the Department of Health and Human Services Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration.


The information technology and consulting firm's Center for Health Dispute Resolution will conduct independent external reviews of Medicare managed care denials. The one-year contract, including four additional option years, is valued at $21,883,705 for a guaranteed base volume of 90,000 external reviews over the five years.


To date, approximately 7 million Medicare beneficiaries have voluntarily enrolled in health management organizations or similar plans. If an enrollee wants to contest an HMO denial, he or she has access to external review through a network of attorneys and physicians developed through Maximus.

Some 24,000 external review cases are being handled each year at the current enrollment level, according to the company.


The Centers for Medicare and Medicaid Services has pledged to expand managed care enrollment for Medicare beneficiaries, which could lead to an increase in the volume of external appeals under the contract, Maximus said in a statement.


"With the impending enactment of federal patient protection legislation, we expect to fully leverage our capabilities and unique expertise providing external reviews and continue to expand this line of business," said David Mastran, Maximus chief executive officer.


Maximus provides of external reviews for new state patient protection programs in more than 20 states, Mastran said.


The Center for Health Dispute Resolution has provided external review services to the Centers for Medicare and Medicaid Services since 1989. As part of the new contract, Maximus' Center for Health Literacy and Communications Technology will support the Center for Health Dispute Resolution in developing appeal notices for low-literate and non-English speaking seniors.

This will be the first known instance of combining literacy techniques with independent external review, Maximus said.