NAIRO Issues Conflict of Interest Position on Interim Final Rules in Response to Request for Comments

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NAIRO, a trade association of independent review organizations (IROs), comments that the Public Health Service (PHS) Act 2719 doesn't adequately protect consumers against health plan conflict of interest as currently drafted. The group urges extending the health reform regulations to eliminate conflict of interest on internal appeals reviews for all health plans.

We recommend strengthening the conflict of interest section of the Interim Final Rules to better protect the healthcare rights of consumers. In-house clinicians are wedded to the success or failure of the health plan for which they work and are subject to management directives. This raises the presumption of conflict of interest, especially when reviewing consumer appeals internally.

NAIRO, a trade association of independent review organizations (IROs), issued public comments on the Public Health Service (PHS) Act 2719 saying, it doesn't adequately protect consumers against health plan conflict of interest as currently drafted. NAIRO's public comments explain how conflict of interest compromises many health plans, because they often use their own doctors to review first and second level internal appeals. The association urges the Department of Health and Human Services (DHHS), Department of Labor (DOL) and the Internal Revenue Service (IRS) policy makers to adopt the same rigorous conflict of interest standards applied to external review.

"At the core of PSH Act 2719 is the notion of consumer protection," said Seana Ferris, President of NAIRO. "We recommend strengthening the conflict of interest section of the Interim Final Rules to better protect the healthcare rights of consumers. In-house clinicians are wedded to the success or failure of the health plan for which they work and are subject to management directives. This raises the presumption of conflict of interest, especially when reviewing consumer appeals internally."

According to the NAIRO position paper, the same conflict of interest standards should be applied to both internal and external appeals. Currently 44 states, the National Association of Insurance Commissioners (NAIC), Utilization Review Accreditation Commission (URAC) and some government agencies recognize strict conflict of interest standards for independent medical reviews.

Conflict of interest standards not covered that NAIRO recommends adding to the regulations include:

  •     Reviewers for a health plan should not be employees of that plan.
  •     Reviewers of internal appeals should not have been involved in the initial denial of benefits.
  •     Reviewers of internal appeals should do so under the auspices of an IRO accredited by URAC or other recognized body and bound by the conflict of interest standards of that accrediting body.

Adopting such standards helps to ensure consumer protection within the spirit of the Interim Final Rules and the Patient Bill of Rights. For the health care system, this means:

  •     Consumers gain a statutory guarantee that internal appeals for all health plans are objective.
  •     Evidence-based reviews applied at the earliest stages of internal reviews will decrease the overall cost of handling consumer appeals.
  •     States and consumers will not bear the extra cost and delays inherent in relying on the external review process to arrive at a fair determination.
  •     Consumer appeals can be adjudicated much more efficiently, which will lead to better quality of care.

"Many leading health plans, to help ensure accurate and appropriate coverage decisions, already use IROs to review their internal appeals, and this is recognized as a best practice," Ferris said. NAIRO urges policy makers to better protect consumers by extending the health reform regulations to eliminate conflict of interest on internal appeals reviews for all health plans. Clarifying Section 2719 to fit the intent of the Interim Final Rules promises consumers that protection."

The formal NAIRO position statement to the DHHS and the DOL is available on the NAIRO website at http://nairo.org/_pdf/uploads/nairosection2719positionpaper.pdf.

About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process. Its members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit http://www.nairo.org.

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Martin Middlewood
NAIRO
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