Letter to Representatives and Senators Recommending External Physician Review Provisions for a Patients Bill of Rights, February 25, 2002

AHQA's recommendations for external review provisions of the Patient's Bill of Rights went to the following members of Congress: Representative Robert Andrews Representative Marion Berry Representative Michael Bilirakis Representative John Boehner Representative Sherrod Brown Representative John Dingell Representative Ernie Fletcher Representative Greg Ganske Representative Richard Gephardt Representative Jim Greenwood Representative J. Dennis Hastert Representative Nancy Johnson Representative Charles Norwood Representative Charles Rangel Representative John Shadegg Representative Pete Stark Representative W.J. "Billy" Tauzin Representative William Thomas Senator Thomas Daschle Senator John Edwards Senator William Frist Senator Judd Gregg Senator Edward Kennedy Senator Trent Lott Senator John McCain Senator Don Nickles February 25, 2002 Dear Representative / Senator: The American Health Quality Association (AHQA) represents the national network of Medicare Quality Improvement Organizations (QIOs, previously known as Peer Review Organizations or PROs). In 1982, Congress established requirements that QIOs be private, independent, physician-led organizations with the medical and statistical expertise necessary to make sensitive medical appropriateness and quality of care determinations for the Medicare program. QIOs are required by Federal law to maintain strict confidentiality in handling provider and practitioner information developed in quality projects or case reviews. Having this expertise and experience, they also work n many areas outside of Medicare. One of those areas is performing independent external appeals of private health plan denials, authorized under most State laws. AHQA is pleased that both versions of patient's rights legislation passed by the House and Senate (H.R. 2563 and S. 1052) include three important external review provisions including: (1) requiring physician reviewers to be "actively practicing" at least two days per week; (2) ensuring the access and reliability of reviews by requiring the certification of a "sufficient number" of review entities; (3) and recognizing in the certification process the qualifications of entities with existing State and/or Federal contracts to do similar review work (such as the QIOs). However, AHQA would like to raise two issues for your consideration. S. 1052 requires external reviews to be performed by one or more actively practicing physician(s) with at least one in the appropriate specialty or subspecialty. This approach was also used in H.R. 2315, the Fletcher bill. H.R. 2563 requires a panel of three actively practicing physicians with at least one in the appropriate specialty or subspecialty. AHQA supports the provision requiring one or more actively practicing physician(s) for several reasons: QIOs currently performing external review services under State laws report that most cases don't require a panel. There are instances when more than one reviewer or even a panel is preferred, for example, a panel may be desired when reviewing experimental disease treatments or when different specialties treat the same condition. Language requiring one or more reviewers allows for this option, when necessary, without making a panel mandatory for all reviews. Meeting tight time requirements for expedited review would be very problematic if a review panel was required for every case. Currently, QIOs can turn around single physician reviews fairly quickly - within two working days for an expedited appeal. A panel could substantially increase the amount of time required to complete a review. Requiring the use of a physician panel for every review would be extremely expensive. Compensating multiple reviewers and preparing additional copies of medical records and other documentation increases costs dramatically. Expenses for an in-person panel hearing would likely exceed $2,000. Insurers and health plans required to bear these costs will undoubtedly pass the burden on to patients or employers through higher premiums. S. 1052 allows the external reviewer to make a determination as to whether the denial of a claim for benefits should be upheld, reversed or modified. That determination is then binding on the health plan. H.R. 2563 permits external reviewers to uphold or reverse a denial. AHQA supports the ability of a reviewer to offer a modified determination. AHQA members feel strongly about the need for the reviewer to be able to offer a modified determination along the continuum between the plan decision and the care requested by the patient or their physician. QIOs with experience in external review have found that reviewers, while agreeing with a patient/physician position on some issues, will often recommend modifications such as a reduction in the requested length of stay or duration of treatment. The reviewer decision should not be strictly limited to upholding or reversing the plan decision without opportunity for modification. If the term "reversal" is intended to allow for some modification, that intention should be made clear in the legislation or the accompanying report language. AHQA appreciates the difficult task of reconciling the differing provisions of the House and Senate legislation. I hope that you will give careful consideration to the concerns presented. Please contact me if I can answer any questions you have regarding our position. Thank you. Sincerely, David G. Schulke Executive Vice President