Recent amendments apply standards of external review
Regulations were designed to provide uniform federal standards to govern consumers' right to appeal denials of claims or coverage by health plans.
Generally, courts require litigants to exhaust all administrative remedies before seeking judicial intervention. Thus, a claimant would be required to exhaust a plan's internal review processes before resorting to external review. Under the 2010 regulations, however, this administrative exhaustion requirement was relaxed such that a claimant could immediately seek external review of benefit denials if the plan failed to "strictly adhere" to all of the regulations' requirements for internal claims and appeals processes.
This amendment effectively removes the "strict" from "strict adherence" and perhaps is more indicative of a "substantial adherence" standard.
In this latest episode of Tuning In to the C-Suite podcast, Briana Contreras, an editor with MHE had the pleasure of meeting Loren McCaghy, director of consulting, health and consumer engagement and product insight at Accenture, to discuss the organization's latest report on U.S. consumers switching healthcare providers and insurance payers.
Listen
Healthcare journalist, HIV advocate and educator Juan Michael Porter II discussed moderating the "Future of Science" session at the International AIDS Society's AIDS 2024 meeting in Munich, Germany, as well as addressing "founder's syndrome" in AIDS organizations and the inclusivity of the event.
Read More
In our latest "Meet the Board" podcast episode, Managed Healthcare Executive Editors caught up with editorial advisory board member, Eric Hunter, CEO of CareOregon, to discuss a number of topics, one including the merger that never closed with SCAN Health Plan due to local opposition from Oregonians.
Listen
