New Standards for Medical Review Organizations: Holding Them and Health Plans Accountable for Their Decisions
Marc A. Rodwin
Suffolk University Law School; Harvard University - Edmond J. Safra Center for Ethics
March 3, 2011
Health Affairs, Vol. 30, p. 519, 2011
Suffolk University Law School Research Paper No. 11-11
Most states have laws that allow patients to appeal to an independent review organization when their health plan or insurer deems a service unnecessary or experimental and denies coverage. The Affordable Care Act requires the Department of Health and Human Services (HHS) to develop standards for these independent review organizations. The standards can help hold review organizations and health plans accountable for their decisions and also can facilitate the evaluation of emerging therapies and technologies as well as coverage policy. To this end, HHS should require health plans and independent review organizations to report basic information, including what medical issues and contested therapies were the subject of appeals, and the grounds for their decisions. What’s more, to preclude conflicts of interest, the HHS standards should prohibit independent review organizations from participating in appeals involving health plans that have employed them for other work.
Date posted: March 6, 2011