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larly important to track the continuity of care across multiple settings, including home health and other long-term-care settings, and to assess the interpersonal aspects of care, such as patient-physician communication.
Managed care plans must also be subject to the ongoing review of professional external quality review and improvement organizations. There are those who would substitute accreditation for external review (Balanced Budget Act of 1995). Indeed, many private purchasers rely solely on accreditation as a means of distinguishing among managed care plans. However, the fact that a plan is accredited merely is an indication that it has the systems in place to produce high-quality care. This represents just a point-in-time description of the plan's capabilities. Beneficiaries need assurances not only that systems are in place but also that there are processes to determine whether the structures and systems are actually working in practice. Therefore, there is a need for ongoing external quality review to detect problems that may not be revealed through an accrediting process.
Grievance and Appeals
Inevitably, in a system that restricts choice and limits care to "medically necessary services," there will be disagreements between the health plan and its enrollees. A critical beneficiary protection is a grievance and appeals process that enables enrollees to receive timely and clear information about the specific reasons for denials of a service or payment and the right to appeal a denial. For vulnerable populations, it is especially important that the methods of communicating information about the grievance and appeals process be tailored to meet their specific needs.
Beneficiaries must retain the right to a review by an independent decision maker outside of the managed care plan, using medical expertise when appropriate, and then access to the federal courts. Of critical importance to vulnerable populations is an expedited review process that includes specific deadlines for situations in which failure to receive care or referral for specialized treatment promptly could jeopardize the patient's health or preclude optimal outcomes. These protections are so essential