CMSA Today - Issue 2, 2012 - (Page 26)

CMSA Case Management and the Law Understanding the New Federal External Review Requirements BY GARRY CARNEAL, JD, MA T he U.S. medical management system is dynamic and always evolving. Most case managers need to be familiar with workflow processes such as utilization management, care coordination, care plans, assessment criteria, appeal requirements, and other key interventions. One of the most complex areas to understand is “external review.” Case managers need to stay abreast of their patients’ rights to file an appeal to independent experts when an adverse medical necessity determination is made. Some case managers also are in charge of setting up the utilization management and external review appeals process for their health plan. Recently, the federal government issued several rounds of “interim” final regulations, along with a technical release, updating the “external review” requirements for insurers under the Patient Protection and Affordable Care Act (“Affordable Care Act” or PPACA). 1 These regulations update ERISA’s claims procedures and give guidance on the new external review process health plans must provide. Ultimately, the new federal external review requirements could apply to more than half of all Americans. Clearly, external review protections are a cornerstone of PPACA: “The right to an external appeal is considered one of the most important consumer protections that you can have,” said Steve Larsen, director at the Center for Consumer Information and Insurance Oversight, a subdivision of the U.S. Department of Health and Human Services’ (HHS). “Consumers do not want insurance companies making medical decisions for them or for their families.”2 However, building and running a seamless external review program is a challenge even for seasoned health care attorneys or regulatory compliance experts. In any given case, health plans must comply with the highest standard and/or requirement. In addition to PPACA’s emerging requirements, potential sources of external review standards come from: • This U.S. Department of Labor regulations adopted in 2002 and any revisions thereafter. TRACKING THE NEW FEDERAL EXTERNAL REVIEW REQUIREMENTS The federal government made several important changes last year to the original interim regulations supporting PPACA (which were originally released in July 2010).4 The 2011 modifications include: • Compliance deadlines. o The implementation date for “nongrandfathered” health plans went into effect January 1, 2012. o States have until January 1, 2014, to transition to the National Association of Insurance Commissioners (NAIC) model act covering external review activities if certain criteria are met. • Temporarily limits the scope of the external reviews to only the “medical necessity appropriateness” determinations.5 Now eligible claims include only those that involve “(1) medical judgment (excluding those that involve only contractual or legal interpretation without any use of medical judgment…), as determined by the external reviewer; or (2) a rescission of coverage.”6 • Restores the maximum timeframe for urgent reviews back to the 2002 DOL standard of 72 hours. The July 2010 interim regulations had proposed a 24-hour turnaround, which was not practicable.7 • Scales back the reporting requirement of diagnosis and treatment codes when an adverse benefit determination is rendered. Although health plans must still provide this information upon request to a health plan member, it no longer has to be automatically reported. • Minor infraction of the external review requirements no longer gives the claimant an automatic opt-out of the appeals process. • Non-English interpretation requirement of using “culturally and linguistically” appropriate language is softened. Now all plans must print notices in the dominant foreign language if 10 percent of the population of a county speaks that language (and not English). Under the previous rules, companies with fewer than 100 employees would have to furnish foreign-language notices in counties where 25 percent of the population spoke the second language.8 26 CMSA TODAY ISSUE 2 • 2012 • DIGITAL

Table of Contents for the Digital Edition of CMSA Today - Issue 2, 2012

2012 Public Policy Summit, April 23-24
Aligning Professional Ethics with Innovation: Licensure Portability’s Predicament
Can You Hear Us Now? What’s Happening with the Multi State Licensure Task Force
The Evolving Role of Care Coordination in an Acute Care Environment: Confi rming the Appropriate Utilization of Necessary Services – Separating Tasks from Process (Part 2 of 3)

CMSA Today - Issue 2, 2012