June 27, 2011
For additional information:
Jason Hammersla

Council commends reexamination of PPACA claims & appeals, external review regulations

WASHINGTON, DC — "With full implementation of the Patient Protection and Affordable Care Act (PPACA) growing ever closer, employer health plan sponsors are under intense pressure to comply with the many new rules and regulations being issued by the Obama Administration," said American Benefits Council president James A. Klein today.

"The Council commends the Obama Administration for responding to a number of concerns raised by the employer community in conjunction with the regulatory agencies' amendment and re-issuance of interim final rules governing Internal Claims and Appeals and External Review Processes," Klein said.

The Council had noted in its September 2010 comment letter that the original rules included a number of unworkable requirements and inadequate timelines for compliance by plan sponsors. One particularly important clarification the Council had urged, that the agencies now acknowledge, was that health claims eligible for external review by independent review organizations should be focused on medical judgment matters, rather than "any" adverse benefit determination.

"The proper role of independent review organizations is to resolve coverage disputes that sometimes involve complex questions such as whether a particular treatment is medically necessary. But it certainly is not appropriate for these organizations to be making legal interpretations of the contractual terms of a health plan. The agencies got it right on this matter." Klein noted.

"While there is still much work to be done on these and other rules related to the new health care law, we are pleased that the Obama administration recognizes the value of employer expertise and cooperation with PPACA implementation." Klein said.

For more information on specific elements of the amended regulations, or to arrange an interview with Council staff on PPACA implementation, please contact Jason Hammersla, Council director, communications, at 202-289-6700.

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The American Benefits Council is the national trade association for companies concerned about federal legislation and regulations affecting all aspects of the employee benefits system. The Council's members represent the entire spectrum of the private employee benefits community and either sponsor directly or administer retirement and health plans covering more than 100 million Americans.