Affordable Care Act

Recent Developments in Health Care Reform

There have been two major developments under the health care reform legislation that were released recently that directly impact independent review.

On July 23rd, the Department of Health and Human Services released the Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes under the Patient Protection and Affordable Care Act. These regulations generally apply to group health plans and group health insurance issuers.

Highlights:

Follows NAIC Model Act
Requires independent review to ensure impartiality
External reviews must be conducted by nationally accredited IROs
Determinations are rendered on issues related to medical necessity, appropriateness, health care setting, level of care or effectiveness of a covered benefit and provides a separate expedited process to address experimental and investigational denials
Allows for review of rescission determinations

On August 23rd, the Department of Labor issued Technical Release 2010-01 for the Interim Procedures for Federal External Review relating to Internal Claims and Appeals and External Review Processes under the Patient Protection and Affordable Care Act. These regulations generally apply to self insured group health plans not subject to a State external review process.

Highlights:

External review procedures are based on the NAIC Model Act
Plans can voluntarily comply with provisions of their State external review process
External review must be conducted by URAC accredited IROs
IROs must have medical and legal professionals to provide expert determinations
Standard and expedited review processes are included that address coverage determinations and medical necessity issues

Implementation may begin on or after September 23, 2010 for many plans or issuers.

IMEDECS:

Is a URAC accredited IRO.
Conducts reviews through state mandated or voluntary external review programs
Conducts reviews for self-insured plans
Conducts medical necessity, experimental/investigational, benefit coverage and rescission reviews
Screens experts for case specific conflicts of interest
Meets the report requirements of the Interim Final Rules and the DOL Technical Release
Complies with the timeframes prescribed under the rules
Has an extensive national panel of experts that includes physicians, attorneys and allied healthcare practitioners
Has a secure web portal through which you can submit the appeals

Questions?:

If you have any questions about our services or qualifications, please do not hesitate to call us (215-855-IMED) or send us a message using our online Contact Form.