Labor & Employment
The Impact of External Reviews on Discretion in ERISA Health Litigation
The uptick in external medical reviews for ERISA health claims has potential consequences when plan administrators seek to assert a discretionary standard of review in federal court. The Affordable Care Act has increased the usage of the federal external review process, in addition to state external review programs. As the final, and optional, appeal opportunity, external reviews make medical necessity decisions which are binding on ERISA administrators. In doing so, the external reviews may result in ERISA administrators relinquishing discretionary authority over health claims.