Treatment disputes in these cases should be resolved before any change in treatment occurs. Outside independent review. A plan denial of medical care should be reviewed by someone having no relation to the plan and no stake in the outcome. Unbiased review is essential in a managed care environment where the health plan's financial incentives may encourage saving money over delivery of appropriate, perhaps expensive, care. In a dispute with a building contractor over what type of flooring should have been installed in your house, you would never agree to let the contractor be the sole judge of the matter, especially where the contractor stood to benefit financially by not putting in what you wanted.
Impartial review is even more important where health and safety are at stake.
We believe that plans are more careful when they know that an objective, external review is part of the process. There are five steps in the current appeal process. This testimony focuses primarily on the first three steps because that is where most cases are resolved. If there is a question or a disagreement about what care should be provided, the plan is required to give the enrollee a written decision, stating in understandable language, the basis for the decision and explaining the enrollee's appeal rights. Every enrollee who disagrees with a denial of care, or with a termination or reduction of care, needs to know the reason for the plan's decision and how to have that decision reviewed.