Recent court cases have cast a shadow of risk among independent review organizations (IROs) and those providing utilization review services.
Two landmark cases – King v. CompPartners and Weil v. Cigna Health et al., both in California – appear to have broadened conventional understanding of the possible liability of IROs and their role in medical coverage decision-making, says Michael Reisman, MA, JD, president of ClearHealth Quality Institute in Annapolis, MD.
Over the past several years, these cases have raised questions about the fiduciary duty among IROs when rendering coverage decisions. They also have brought attention to questions of liability pertaining to clinical decision-making, says Reisman, who will present a session titled “An Overview of How Legal and Regulatory Trends Are Impacting Health Insurance Appeals” during the NAIRO Trust in Healthcare Symposium in Nashville, Tenn., in October.
While the California Supreme Court ultimately ruled to depublicize, or overturn, the King v. CompPartners case, which sought to hold utilization review physicians responsible for the care of patients, the fact that such cases are cropping up is a good reminder that the review industry is being challenged as more attention comes to internal and external review processes.
“There is legal risk facing health plans and IROs, but it remains to be seen how much risk there is,” says Reisman about the prevailing legal issues surrounding external appeals and review.
Reisman points to the Weil v. Cigna Health case as a good example of how coverage decisions are coming under increased scrutiny. In that case, the plaintiff, Annette Weil, brought a complaint against her insurer, Cigna Health, because the insurer had denied Weil coverage of transcranial magnetic stimulation (TMS) to treat her severe case of depression. Cigna deemed the TMS treatment an experimental and investigational service, thereby denying coverage.
Such cases highlight a larger trend, one that speaks to a growing, if still muted, sense of risk that permeates the internal and external review industry, largely related to the fiduciary responsibility of an IRO when it is contracted by a health plan to render decisions regarding the medical necessity or experimental and investigational nature of a service.
“Traditionally, an IRO was thought to have no fiduciary duties to a health plan member,” says Reisman, who will explore in further detail how the landscape is shifting when it comes to liability issues at the Trust in Healthcare Symposium.
As the leading conference for the independent external review industry, the NAIRO Symposium offers a forum for all stakeholders to come together, discuss the most relevant issues impacting the work of IROs and UR organizations, and understand the nuances of external review and appeals – and ultimately broaden how the wider healthcare community perceives this vital part of health care.
The NAIRO Trust in Healthcare Symposium takes place Oct. 16-18 and features three days of education, networking and information-sharing. For more on the Symposium, and to register, see here: www.eventbrite.com/e/nairo-trust-in-healthcare-symposium-registration-36081562926.