Opinion ID: 3010672
Heading Depth: 4
Heading Rank: 1

Heading: Origin and Function of the PRO and PRO NJ

Text: Congress enacted the Medicare program in 1965 to establish a federally funded system of health insurance benefits for the aged and disabled. See Social Security Amendments of 1965, Pub. L. No. 89-97, 79 Stat. 286 (codified as amended at 42 U.S.C. SS 1395 to 1395ccc (1994)). In 1982, Congress amended the Medicare statute by enacting the Peer Review Improvement Act of 1982, Pub. L. No. 97-248, S 143, 96 Stat. 381 (1982), which established a new method of reviewing the quality and appropriateness of the health care provided . . . to Medicare beneficiaries. American Hosp. Ass'n v. Bowen, 834 F.2d 1037, 1041 (D.C. Cir. 1987). The Act requires that the Department of Health and Human Services (HHS) enter into contracts with peer review organization, or PROs, private organizations of doctors that review, inter alia, whether medical services were reasonable and medically necessary and whether the quality of such services meets professionally recognized standards of health care .. . . 42 U.S.C. S 1320c-3(a)(1)(A), (B). In essence, the Act functions as a quality and fiscal check upon the medical services of physicians and institutions which provide health care services under the Medicare and Medicaid programs. Todd v. South Jersey Hosp. Sys., 152 F.R.D. 676, 685 (D.N.J. 1993). PRO NJ is a PRO incorporated in the State of New Jersey. PRO NJ was successful in obtaining the first contract with 11 the Health Care Financing Administration (HCFA) of the HHS and has maintained a contract for Medicare Peer Review in the State of New Jersey since 1984 on a continuous basis. Prior to 1984, the predecessor to PRO NJ, The Southern New Jersey Professional Standards Review Organization, and Area VII Physician's Review Organization, Inc., maintained Medicare peer review contracts with HHS.