Gearing Up for Expanded External Review Requirements

by Pat Stricker, RN, MEd
Senior Vice President, Clinical Services
TCS Healthcare Technologies

The concept of "external review" is familiar to most case managers. The ability for patients or their providers to appeal an adverse medical necessity or benefit determination has been around for years. However, a new national framework for such appeals is being established through the Patient Protection and Affordable Care Act (PPACA).

Last June, the U.S. Department of Health and Human Services (HHS) and U.S. Department of Labor (DOL) issued a revised technical release updating the new federal "external review" requirements. Simply put, health plans issuing new policies and offering "non-grandfathered" coverage must provide individuals an expanded reconsideration and appeals process when an adverse determination is made. After several draft regulations were published and a six-month delay, key provisions of the new federal law go into effect January 2012.

The relationship between case management and external review is an important one. "The right to an external appeal is considered one of the most important consumer protections that you can have," said Steve Larsen, director of HHS’ Center for Consumer Information and Insurance Oversight. "Consumers do not want insurance companies making medical decisions for them or for their families." As a result, case managers play a vital role in helping patients navigate and find balance between their medical care needs and service reimbursement.

Unfortunately, identifying which set of appeal rules apply is not always easy. Under existing requirements and PPACA, several sources of external review requirements might apply to a given situation, including:

Section 2719 of PPACA
U.S. Department of Labor regulations adopted in 2002
The Uniform Health Carrier Review Model Act issues by the National Association of Insurance Commissioners (NAIC)
Most states have adopted an independent or external review regulation already (see comments below)
URAC and NCQA’s accreditation standards for external review and independent review organizations

The federal government notes that in some cases state-based external review requirements may be sufficient to meet and/or exceed the new federal requirements. Currently, HHS is determining which states meet or exceed the new federal requirements.

All of these potential variations can be overwhelming for patients, providers, and for all of us working in case management. However, this is where technology comes in. Several software applications are being configured to help automate some of these key external review decision points. When done correctly, key workflows and regulatory requirements can be integrated and streamlined, which in turn will allow providers and case managers to continue focusing on the patient.

I encourage you to take the time now to review the requirements to determine how they might affect your workflow processes. You may be surprised to find that you are lucky and they won’t affect you at all. However, if you do have to make changes to meet the requirements, at least you will have time to make them before they are needed. It’s always best to be prepared and plan ahead.

In the meantime, regulators still need to sort out all of the nuances associated with PPACA’s new reforms. Even if some of the reforms are repealed or scaled back in the future, IT systems and applications will continue to empower case managers and providers to do more for their patients. We are living in exciting times indeed. Challenging - but exciting!!

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