Interpreting the Internal-External Appeals Regulations White Paper Issued by NAIRO
The Interim Final Regulations (IFR) are a set of multi-agency documents health plans must interpret to assure they are complying with the requirements for internal and exteral appeals. To help organizations clarify these documents, NAIRO, has issued a white paper.
Westerville, Ohio (PRWEB) January 5, 2011
To make it easier for health plans, third-party administrators and self-insurers to comply with the Interim Final Regulations (IFR), NAIRO, the trade organization of independent review organizations (IRO), has issued a white paper to explain the IFR and the new internal and external appeal rules and the use of IROs.
Uniform Appeals Processes
The IFR is a collection of documents that includes Section 2719 of the Patient Protection and Affordable Care Act (PPACA) and related technical releases from the Departments of Labor (DOL) and Health and Human Services (HHS). The intent of these documents is to protect consumers and provide consistency for health plans through a uniform approach for processing internal and external appeals. It mandates when plans and issuers must comply with applicable state or federal external review processes and the minimum requirements that state external review processes must meet. However, each of the relevant documents that comprise the IFR addresses different internal and external appeal requirements. This makes it difficult to determine whether plans are complying with the IFR.
"The two areas most confusing for health plan administrators and others wanting to comply with the IFR include conflict of interest and the application of the three IRO rule," said Seana Ferris, President of NAIRO.
Complying with the Three IRO Rule
To ensure unbiased and independent decisions, those plans not subject to their state's external review laws; plans in the states with no state external review laws; and those in states that do not meet the minimum standards of the Uniform Health Carrier External Review Model Act, after July 1, 2011 must comply with the Federal External Review Process. This process requires those plans to contract with at least three URAC-accredited IROs to conduct an external review. The NAIRO white paper helps to clarify the three IRO rule and addresses the following issues:
States without external review processes in place. The Federal External Process applies only to those states without an already established external review process in place. When the IFR was enacted, Alabama, Mississippi, Nebraska, and North Dakota were the only states without external review processes in place, and therefore must follow the federal process.
ERISA self-funded plans. Self-funded plans have a choice. They may choose to follow their respective state external review laws or the federal process. Some self-funded plans do not want to submit to the external review regulations. To further complicate the situation,, many states indicate that they will not allow these plans to follow their external review laws. This makes it difficult to understand the ERISA self-funded plan relationship with IROs.
When external review does not apply directly. Plans in states with external processes that do not apply directly to them (for example, some state processes only apply to HMOs) may choose to participate voluntarily in the state's process rather than the federal process--if the state will expand their coverage to include these plan types.
Avoiding Conflict of Interest
The IFR requires that claims and appeals be decided in a way ensuring the independence and impartiality of anyone making benefits determination. Under the IFR, conflict of interest is limited to health plans not making any hiring, firing, promoting, compensation or similar decisions about an individual evaluating a claim, based on the likelihood that that person would deny that claim.
IROs already meet or exceed the strict conflict of issue standards established by URACand NAIC. In fact, many state regulatory bodies have similar conflict of interest requirements. By adhering to these standards, IROs also meet the DOL conflict of interest standards, which mandate that a reviewer cannot review a claim where the reviewer has consulted with or worked under someone involved in the adverse benefit determination.
Despite exceeding the IFR and state standards, some health plans are concerned whether IROs performing both internal and external reviews for the same client have a conflict of interest. "NAIRO does not believe that an accredited IRO performing both internal and external claims for the same client has any conflict of interest if the IRO follows the URAC and NAIC standards," Ferris said.
The NAIRO white paper, "How to Interpret the New Internal and External Appeals Regulations," is available for download at http://nairo. org/_pdf/uploads/nairo_appeals_whitepaper. pdf].
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process. Its 23 member organizations embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit http://www. nairo. org].
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