Benefits Improvement and Protection Act (BIPA) 2000 Medicare Appeals Process Analysis and Recommendations Background - Subtitle C, Section 521 of BIPA 2000 established an independent external review process for all Medicare fee-for-service appeals. The American Health Quality Association (AHQA), representing the network of state-based Peer Review Organizations (PROs), supports this expansion of independent review. The PROs were established by Congress to apply their medical review expertise to inpatient care decisions for Medicare beneficiaries, including the timing of hospital discharge, the appropriateness of initial payment decisions through the payment error prevention program (PEPP) and specific DRG payments. In addition, the PROs perform independent review for private insurers in many states and have supported federal legislation to create an independent review process for all privately insured patients. The Problem - Instead of offering beneficiaries this well-established network of experts to hear their newly allowed appeals, the legislation created a new layer of reviewers for HCFA to manage. Further, it gave one of the most critical beneficiary rights to review - the quick turnaround of reviews that determine the timing of hospital discharges - to these untested entities. Under this new law: Beneficiaries will not get independent review from the experts. Less experienced regional or national organizations, with fewer required qualifications, will be entrusted with sensitive medical necessity decisions. Beneficiaries deserve the most expert review possible. Medical necessity decisions made by local physicians could be overturned by an entity with little physician input. The statute establishing the PRO program was very explicit about the need for physician involvement in decisions to overturn initial coverage determinations. These new entities will not be subject to these same statutory requirements. Limited federal resources will be wasted. The American public should not be charged twice for the skills and infrastructure needed for this new independent review process. In addition to the infrastructure of individual organizations, HCFA will be forced to develop a parallel contracting process. The new process will create confusion for beneficiaries and providers. This legislation establishes a separate method for reviewing fee-for-service and M+C beneficiary hospital discharges. Currently, the PRO can review both fee-for-service and M+C hospital discharges. Recommended Solution - The legislation should be amended to recognize that Congress already created organizations to provide independent review for Medicare. The role of the PROs as independent external reviewers should be expanded and the PROs should retain their responsibility for performing the review of hospital discharge appeals.