RegQuest™, one of the nation’s premier online regulatory compliance resources focusing on medical management and insurance functions, announces the release of the External Review Regulatory & Market Trends: 2016 Annual Report (ER Trend Report). The report, based on a detailed regulatory survey, academic research and expert interviews, provides a comprehensive overview of external review (ER) regulations, trends and practices.
As the first comprehensive survey of both state and federal regulations performed on ER regulations and industry trends, the report is a must-read for anyone interested in learning how the external review of a medical management appeal is performed. The study was conducted with the assistance of the National Association of Independent Review Organizations (NAIRO).
“Studies have found that most Americans are not aware that they can appeal an adverse benefit determination to an external, independent third party,” notes Garry Carneal, JD, MA, RegQuest Founder and Senior Policy Advisor to the Kennedy Forum. “A predominant trend throughout the research is the need for more education and communication with patients to inform them of their rights.”
“The ER Trend Report illuminates the important role of external review in the medical management process. Third party review maintains the fidelity of the appeals process and serves as an important check to ensure that appeals are properly processed,” remarks Gib Smith, JD, Executive Director of NAIRO. “External review requirements protect the rights of patients and ensure that care is appropriately delivered and reimbursed.”
The report also examines a number of issues facing the ER process, including under-utilization of the system, alternative benefit appeal programs, and recent litigation efforts focusing on fiduciary requirements.
“While the external review process is an important step forward, we must continue to refine and improve upon the process” states Meiram Bendat, JD PhD, Founder and President of Psych-Appeal, Inc. “This report details both the challenges facing the external appeals system and suggests some useful solutions towards working to a more transparent, consistent and even-handed process.”
Julie O’Brien, RN, BSN, MS, President of NAIRO and President of the Alicare Medical Management, notes, “It is our hope that the External Review Regulatory & Market Trends: 2016 Annual Report will not only serve as a helpful guide to navigate this complex regulatory environment, but that it will also stimulate public policy debate to identify best practices in terms of compliance with regulatory requirements and updates to key medical management practices by payers.”
In addition to Bendat, Carneal and Smith, the ER Trend Report co-authors include Tom Naughton, JD, President of MAXIMUS Federal Services Health Division, and Catherine Fulton Spivey, JD, Senior Legal Counsel to RegQuest, LLC and Legal Advisor to the Kennedy Forum. O’Brien wrote the Foreword to the ER Trend Report.
To access an executive summary of the ER Trend Report, click here. Copies of the full-length ER Trend Report are available to RegQuest subscribers. Subscribers enjoy access to RegQuest’s comprehensive database of state laws and regulations focusing on external review, utilization management and grievance and administrative appeals for $895 annually. In addition to the ER Trend Report, subscribers have access to educational webinars, a blog, additional white papers and trend reports, and will be alerted to any updates that might affect the medical management industry. To subscribe, please visit www.RegQuest.com.