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Patient safeguards, including independent appeals and continuity of ongoing care, will soon be a part of health plan requirements for accreditation by the National Committee for Quality Assurance (NCQA) in Washington, DC.
As state legislatures and Congress consider adding consumer protections, the NCQA announced that Accreditation 2000 will incorporate several of them.
"We think the role of NCQA is to standardize these efforts," says spokesman Brian Shilling, who notes that 20 states and several health plans already provide for independent appeals. "[The independent appeal provision] has a lot of support from the health plan community as well as consumer organizations."
Accreditation 2000 standards are still in draft form, with a final version due in late summer. They would require health plans to:
• Provide an independent review process when members have exhausted a health plan’s internal process.
NCQA will likely set up a certification program for independent review organizations to ensure that they have appropriate medical expertise.
• Ensure that a "same or similar specialist" as the one involved in the member’s case evaluates the denial in at least one level of the internal appeals process.
• Allow patients to continue with care for an active course of treatment for up to 90 days if the provider has been dropped from a health plans network. For example, pregnant women would be covered by this standard.
• Provide minimum access to behavioral health patients. Accreditation 2000 also focuses on coordination of care of behavioral health and medical providers.