Assuming some form of health reform legislation is adopted shortly, one aspect that is likely to be included is the Senate version of a new appeals procedure for denied or disputed claims. The idea behind this is to make rules that apply to insured plans also apply to self-insured employer plans regardless of the fact that strong ERISA appeal rules are in place today. The new rules require external an appeals procedures under rules that follow the NAIC Uniform External Model Act or standards adopted by the Secretary of HHS.
External review is used by many large employers to obtain an independent medical review of a disputed claim especially where medical necessity is the questionable issue. Now we are talking about going further in the process. For example, under the proposed legislation benefits must continue until all appeals are resolved. It is difficult to see exactly how this would work. Let’s say the dispute is continuing chiropractic care or mental health counseling, a claim would arise when a claim is processed and benefits are denied, will a patient continue denied treatment and for how long? If the appeal is denied, who is responsible for the treatment received? Alternatively, perhaps the denial is of a predetermination for a major medical procedure, if the procedure must be covered until the appeal is resolved who accepts the potential liability? Extensive regulations are no doubt on the way, but for employers and insurers the complications and additional work are significant.
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