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PPACA: Independent Denial Reviewers Call for Changes

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Regulators should make the health plan decision appeals process more independent, according to a group that represents independent review organizations.

The National Association of Independent Review Organizations, Westerville, Ohio, says the Affordable Care Act – the federal legislative package that includes the Patient Protection and Affordable Care Act (PPACA) – includes a provision that will require health plans to impose effective internal and external appeal processes when they deny coverage for medical procedures.

But health plans still can use their own doctors to conduct the first level of appeals, and they often can use their own doctors to conduct the second level of appeals, according to NAIRO.

Federal agencies already have required self-funded employer health plans to offer members independent medical reviews of appeals, and the agencies now should offer the same access to independent appeals to members of insured plans, NAIRO says.



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