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extreme was a contract that described the company's services in fewer than four pages.
Notwithstanding the differences from contract to contract in the amount of detail about the organization's services (for example, the options available when an initial negative determination of medical necessity has been made), a reading of the contracts does not reveal substantial differences among organizations in the services themselves.
Sources of Clinical Criteria and Standards
The review-of contracts suggests that employers and other purchasers apparently have not required information about the sources of the clinical criteria and standards used by the organization with which they contract for review services. Little or nothing in the contracts describes the criteria or indicates their sources. One contract states that medical review will use ''recognized norms and standards, of the medical need for and appropriateness of proposed, ongoing or completed medical care.'' Regarding hospital admission review, the most comprehensive and detailed contract stated only that the review firm will evaluate proposed admissions to certify "medical necessity and appropriateness under the [insurer's] benefit plan." Another contract refers to "guidelines mutually agreed upon" by the contracting parties. The most specific contractual statement about criteria stated that the review organization would use the purchaser's "accepted review criteria and guidelines as the framework for making appropriateness decisions." These guidelines included the 1986 InterQual ISD-A criteria (intensity of service, severity of illness, discharge, and appropriateness screens).
There may be extracontractual discussions and negotiations between the review organization and client regarding the criteria used to evaluate the necessity or appropriateness of care. However, these agreements, like most commercial contracts, state that the contract is the entire agreement between the parties and that the agreement cannot be modified, except by action of both of the parties.
Distinction Between the Review Determination and Purchaser's Decision To Pay For Services
Most of the contracts that were reviewed contain specific language about the distinct roles of the review organization and the purchaser. The contractual agreements generally specify that the review organization makes no decision respecting benefits, although an adverse review decision often will be the basis for an adverse decision on benefits. Note the following disclaimer language in one contract: