Federal External Reviews
& Healthcare Reform

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Healthcare Reform

The Patient Protection and Affordable Care Act (PPACA) was enacted on March 23, 2010 and requires employer-sponsored group health plans to a torrent of statutory and regulatory provisions, which continue today, including numerous coverage expansions and mandates as well as several delays, repeals and challenges of future requirements. One of the most significant results of this regulation is that patients and consumers finally have a standardized process under which to appeal health plan decisions, both for internal claims and appeals and external review. Section 2719 of the PPACA and the related technical releases from the Department of Labor (DOL), Department of Health and Human Services (HHS) and the Treasury Department detail the new internal and external appeal provisions. The Interim Final Regulations (IFR) pertaining to internal and external review provide the standards for processing internal claims and appeals; the basis for determining when plans and issuers must comply with applicable state external review processes or federal external review processes; and the minimum requirements that state external review processes must meet.

Early in 2010, as healthcare reform was unfolding, MRIoA adopted an innovative approach and was proactively preparing for the upcoming changes. A specialized team of professionals was assembled who closely monitored the unfolding requirements and expanded MRIoA's processes and infrastructure, upon which our thirty year history of providing state external review was founded, to be compliant with the regulations. In the early days of stakeholder confusion about interpretation and frequent collaboration, as well as continued current vendor solicitation, MRIoA has consistently received accolades regarding the scope of their knowledge, resources and implemented processes.

As one of the nation's largest and most respected Independent Review Organizations, Medical Review Institute of America, Inc. (MRIoA), is positioned to assist health plans nationwide with ALL their review requirements.

Internal Claims and Appeals:

As a URAC accredited organization, MRIoA's Health Utilization Management Accreditation qualifies us to partner with health plans to meet their needs and comply with the PPACA's expanded requirements of internal claims and appeals processes.

Federal External Reviews:

As a URAC accredited Independent Review Organization (IRO), MRIoA is an incomparable choice for plans to meet the PPACA's requirement to contract with accredited IROs to perform external reviews.

  • Plans must contract with at least two IROs by January 1, 2012 and at least three IROs by July 1, 2012 and rotate assignments among them.
  • Note the "Three IRO rule" is specific to external review and does not apply to internal appeal processes.

A broad scope of claims is eligible for external review under the Federal external review process. Generally, any adverse benefit determination is eligible unless it is related to a failure to meet eligibility requirements. An amendment to the regulations on June 24, 2011 temporarily narrowed this scope to include only:

Adverse benefit determinations that involve medical judgment, as determined by the external reviewer including but not limited to, determinations based on:

  • Medical necessity
  • Appropriateness
  • Healthcare setting
  • Level of care
  • Effectiveness of a covered benefit
  • Experimental/investigational
  • A rescission of coverage

It is anticipated that the broader scope of eligible claims will be reinstated no later than January 1, 2014.
By contracting with MRIoA, your organization is assured that external reviews are:

  • Unbiased and independent decisions
  • Free from conflicts of interest
  • Conducted by clinical reviewers or legal experts who meet established qualifications
  • Reviewed using current evidenced-based guidelines
  • Completed within the mandated time periods
  • Processed in compliance with URAC's IRO accreditation standards which mirror those of the NAIC's Health Carrier External Review Model Act

MRIoA has an established and experienced team of "subject matter experts" knowledgeable about the review requirements resulting from healthcare reform. We continue to serve as a trusted resource for clients today and are committed to remain proactive in responding to the inevitable future developments. We look forward to supporting you with your healthcare reform related questions: for assistance please contact our Director of Regulatory Compliance, Aja Ogzewalla at 800-654-2422, Ext. 6475.

 

United States Department of Labor / Employee Benefits Security Administration

http://www.dol.gov/ebsa/healthreform/

Regulations

Technical Releases:


Status of State External Review Processes

EBSA Final Rules & Guidance for Compliance

http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=25819

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