MANAGED HEALTHCARE UNLIMITED CITES TOP FIVE COMPLIANCE CHALLENGES FACING HEALTH PLANS IN 2009

 

January 22, 2009 -- Long Beach, CA - Health plans across the nation should be gearing up now to face new regulatory compliance challenges in 2009, according to Managed Healthcare Unlimited, a national organization that provides expertise in health plan evaluation and compliance.

"Health plans large and small will be facing increasing regulatory scrutiny from Congress, the states and consumer watchdog groups in the coming year," said Rose Leidl, president of Managed Healthcare Unlimited. "Some of this increased oversight comes as the result of heightened consumer outcry against claims denials, underwriting issues and rescission policies that resulted in investigations that grabbed national attention this past year. But additionally, health plans are facing new coverage mandates and timelines that will require extensive changes in how they do business."

According to Leidl, the top five compliance challenges health plans must gear up to face in 2009 include the following:

  • 1. Underwriting and Rescission Practices - Over the past several years, five major California health plans were the subject of an intensive investigation that made headlines and resulted in millions of dollars in fines and the reinstatement of thousands of insureds. The health plans were charged with post-claims underwriting and improper rescission practices - defined as retroactive cancellation of an individual's health insurance after medical claims are filed. Although not all of the California settlements are final, the problems exposed in California reveal the need for a greater understanding of and focus on state rescission guidelines. Congress now has joined with states, consumer watchdog groups and individual claimants to actively investigate and take action against health insurers who revoke coverage retroactively.
  • 2. Mental Health Parity -- In October, 2008 Congress approved legislation designed to improve mental health benefits for insureds in medium and large employer-sponsored group health plans. The law, which becomes effective in 2010, requires payers and insurers that cover mental health treatment to offer benefits no less comprehensive than those provided to chronic or catastrophic medical conditions, such as cancer or diabetes. Once the regulatory specifications for this new law are written by the legislature, health plans will have only a limited period of time to develop their new underwriting guidelines, systems and services and evaluate their policies for compliance.
  • 3. Privacy and Security Regulations -- In 2008 the California expansion of its privacy and security regulation (SB1386) was landmark in that it was the first data security breach law to be approved by a state legislature. The law requires businesses to protect against and disclose any security breaches of personal information, medical data and health insurance information. Other states are expected to follow and seek passage in 2009 and 2010. Doctors must now protect against unauthorized viewing of patient records within the office as well as disclosure of information to outside persons.
  • 4. Language Assistance - Health plans must be familiar with the increasing number of state requirements for assessing and servicing the linguistic needs of enrollees, providing appropriate translation/interpretation services, as well as providing oversight of the language services used by their medical providers.
  • 5. Quality Assurance - In 2007-2008, regulators heightened their focus on quality of care and services. Health plans must demonstrate effective quality assurance mechanisms to ensure that care delivered to members meets professional standards of practice. A fair and reasonable grievance and appeals process and an effective peer review system are critical indicators.

 

"Today, with a national focus on healthcare reform, and greater demand for parity, quality and comprehensive services in health plan coverages, scrutiny of health plan practices is sure to increase," added Leidl. "Even organizations with strong compliance programs in place should consider reviewing and shoring up their processes and procedures to prevent unexpected problems."

ABOUT MANAGED HEALTHCARE UNLIMITED:
Managed Healthcare Unlimited is a leading organization providing expertise in health plan regulatory evaluation and compliance. For two decades, Managed HealthCare Unlimited has worked closely with healthcare organizations to evaluate quality assurance issues, medical survey coordination and monitoring, access and availability of services, systems procedures, and best practices. Managed Healthcare Unlimited assists healthcare organizations in understanding State and Federal compliance requirements and in helping assess and improve their compliance practices. For information, visit http://www.managedhealthcareunlimited.com/.

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