State Regulations and the Independent Medical Review Process

When it comes to health plan administration, appeal of denied benefits, and other types of regulations that effect the healthcare industry, it’s no secret that healthcare is regulated primarily at the state level. This state focus on health care regulation adds of complexity to the independent review process. For health plans operating across multiple states and multiple regions of the United States, it adds costs as well.. We believe that there needs to be a streamlined set of national regulations that will make it easier for health insurance carriers and other companies administering health plan benefits to do business in multiple states without having to have multiple and redundant peer review panels. Operating in multiple states also increases the infrastructure to support, administer and track state regulations.

For an Managed Care Organization or a Third Party Administrator or an Independent Review Organization, working in multiple states as can be an administrative and bureaucratic nightmare. It shouldn’t be this way. We believe that streamlining state regulations and unifying them under national standards would go a long way toward making it easier for healthcare organizations to do business in more than one state and reduce the overall cost to their members. Healthcare regulations are far to complex and the regulatory burden that most healthcare organizations are under adds unnecessary costs. Those costs are passed on to consumers and have a negative impact on everyone.

As an Independent Review Organization, we do business in more than 40 states. In many states, our clients require that we have board-certified physicians in active practice who are licensed in the state where the health plan operates or where a case is being reviewed. To respond to this we have developed a peer specialist panel of over 300 physicians across the country. We add and credential physicians in specific states only to meet state regulatory requirements and this adds costs to the independent review process. Ultimately, these costs are born by the health plan or by the consumer. If there are national medical standards when it comes to medical education, why aren’t there national standards when it comes to licensing physicians?

Other professions have national credentialing organizations and national licensing requirements. But in the medical area, states still feel that it’s their responsibility to license and credential medical personnel practicing within their borders. This turf protection adds no value and doesn’t improve the overall quality of medical care in the United States today. Instead, it adds more burden. We would like to advocate for single, national, licensing requirements for physicians that would greatly simplify the ability of physicians to work across state lines, while still ensuring effective standards advocate the highest quality care and patient safety.