The expanding role of independent review organizations (IROs) in handling consumer-originated external appeals of health plan coverage decisions under health reform is the subject of a morning seminar slated for later this winter in Manhattan. Sponsored by the Northeast Business Group on Health (NEBGH) and moderated by IPRO, the session will examine the intricacies of appeals rights and procedures, both in the Affordable Care Act and in implementing regulations issued jointly by the US Department of Justice, the US Department of Health & Human Services and the US Department of Labor. IPRO is one of a handful of organizations already conducting external IRO reviews under state law. Health reform mandates expansion of external review rights to all Americans with private health plan coverage-whether fee-for-service or managed care-including newly insureds and enrollees in self-insured plan offerings. The total number of individuals with new appeals rights is scheduled to reach 41 million this year. For more information about this breakfast event, including registration, contact Jennifer Cole at NEBGH at firstname.lastname@example.org, (212) 252-7440, ext 223.
IPRO’s identification of wasteful and fraudulent services billed to Medicaid in New York is resulting in substantial recoveries, under an innovative State and County-based demonstration program. Under the twelve-county pilot that began in 2006, local governments share in net savings resulting from audits and investigations undertaken in collaboration with New York State. In Westchester County, where IPRO is the County-designated Medicaid oversight auditor, total federal, state and local recoveries are well over $3.4 million since the program began. “Westchester County’s commitment to this Demonstration program has begun to pay dividends for taxpayers,” according to New York State Association of Counties Executive Director Stephen J. Acquario. “It will continue to prevent waste and abuse in the Medicaid Program and save money for Westchester County taxpayers.” According to New York State Medicaid Inspector General James G. Sheehan: “This kind of cooperation helps the state to protect the integrity of the Medicaid program so that funds are available for those in need.”