NCQA: External Appeals Debut in New Standards
The National Committee for Quality Assurance releases its draft Accreditation 2000 standards today, which would evaluate health plans for an independent appeals process, continuity of care and access to behavioral health care. Under the new standards, health plans seeking accreditation would have to allow patients who have exhausted internal appeals processes to turn to an independent review organization approved by the NCQA. The NCQA will decide later this year whether the review organizations will be evaluated based on an existing certification program or by a new program established by the NCQA. The AP/Dayton Daily News reports the independent appeals standard is likely to prove popular with business leaders eager to restore consumer confidence in the managed care industry and may help stave off further regulations such as right-to-sue provisions brewing in both state and national legislatures. "This is another important private sector voice lending its support to the idea of outside review," said Susan Pisano, spokesperson for the American Association of Health Plans, which last month urged its members to adopt external appeals (3/16).
Other benchmarks included in the Accreditation 2000 standards:
- Coverage decisions for specialty care would be made by appropriate specialists.
- Patients undergoing active courses of treatment such as chemotherapy or obstetrical care would be able to continue to see doctors who are no longer part of the network for up to 90 days unless the doctor was dropped for quality reasons.
- Referral and triage decisions for behavioral health care would be made by staff supervised by a behavioral health care provider with a minimum of a master's degree and five years of experience, and wait times for behavioral health care would range from immediate access for patients with life-threatening disorders to 10 days for routine office visits.