Qualified health care professionals, including clinical peers not involved in the care of the patient, should review the initial treatment decision and subsequent review decisions. Patients should know of their grievance rights regarding adverse decisions, and they should be assured that their records remain confidential throughout the review process. External review should provide for de novo review to ensure fairness to both the plan and patient, and it must be independent and free of bias or conflicts of interest. Certainly, patients should attempt to resolve their differences with plans before seeking judicial remedy. However, internal and external appeals processes, no matter how protective of patient interests, can not substitute for legal accountability.
Patients can still suffer injury or death even with access to a fair appeals process.
The appeals process should not be adopted in lieu of a patient's right to seek legal accountability for plan decisions. Determination of Medical or Clinical Necessity . Today managed health plans act as providers of care, directly influencing care through utilization review and other cost containment techniques. These plans, in an effort to control costs, determine the type, quantity and quality of care that patients receive. The standard of medical or clinical necessity that a plan uses, either through contract or otherwise, during review of care, should be tied to generally accepted principles of professional medical or clinical practice.