Independent Review Organizations (IROs) exist to “ensure thatevidence-based and objective physician review services are provided along the continuum of care. IROs act as a third part and help alleviate the pressure of reviewing claims and make decisions without influence from either end of the situation.” We’ve been talking a lot about the major benefits that external IROs can provide, from helping support effective decision making to giving objective, unbiased reviews. We thought we would take this week to give some IRO basics, for those who want help understanding exactly what IROs are and what they does.
- Q: What is an IRO and what does it do?
- Q: How do IROs work?
- Q: What are the most common styles of procedures IROs review?
- Q: How do I choose the right IRO for my organization?
- Q: What kind of coverage must I have to use the IRO process?
- Q: At what point should I request an external review?
- Q: Who is on the panel of the Independent Review Organization?
- Q: How can I initiate an external review?
- Q: Can I request an external review of any denied claim?
- Q: How long will it take for the external review to be performed?
- Q: Can I appeal the IROs’ decision if I am not happy with it?
- Q: What are the common benefits of using an IRO?
Q: What is an IRO and what does it do?
A: IRO stands for Independent Review Organization. IROs are entities that conduct independent external reviews of adverse determinations involving appropriateness of care, medical necessity criteria, level of care, and effectiveness of a requested services. Many healthcare organizations that process claims require a review be conducted by an IRO. Sometime a provider conducts the claims review and the IRO conducts a verification review.
Q: How do IROs work?
A: IROs typically have both onsite & offsite work. However, in situations where the required documents can be appropriately and effectively provided to the IRO without visiting the provider’s location, most of the work can be done remotely. Offsite work can often mean less disruption for the ordinary business of the organization.
Q: What are the most common styles of procedures IROs review?
A: Transplants, Oncology care, Bariatric surgery, and HGH therapy.
Q: How do I choose the right IRO for my organization?
A: Choosing an IRO can be stressful, especially when there’s so much on the line: money, professional integrity and in some cases, adherence to government standards. Choosing an IRO needn’t be a headache. To find a URAC Accredited IRO, please visit the URAC website. It’s also important to keep in mind that selecting an IRO that is accredited equals a guarantee that the services provided will meet an industry described and selected standard of quality. Therefore, you do not have to worry about the quality of the reviews performed, or any conflict of interest when it comes to reviews for your patients. An accreditation acts as a external mark of approval, showing that that organization is committed to delivering the best quality of services possible. Always make sure to in to account customer service ratings, technology, and expertise when selecting an IRO for you organization. Read this blog post to learn what to look for in an IRO.
Q: What kind of coverage must I have to use the IRO process?
A: Patients with coverage provided through major medical health insurance plans, including HMOs and PPOs and public employee benefit plans can utilize the IRO process.
Q: At what point should I request an external review?
A: When you have exhausted the internal appeal process through your healthcare coverage provider. “”You don’t have to wait until your claims are denied to start using an IRO’s services, though. In fact, your organization would likely do well to utilize an IRO before the denials start rolling in. Periodic external assessments of your operations will help you to catch vulnerabilities and correct them before they cost you money in denied claims. Whether it’s concerns of efficiency, technology integration or the structural integrity of your organizational hierarchy, the information to be gleaned from an IRO certainly won’t hurt your strategic plan.”
Q: Who is on the panel of the Independent Review Organization?
A: Physician Advisors who are experts in the field related to your medical condition will review the case. These Advisors typically go through a rigorous screening and credentialing process before being selected as a Physician Peer Reviewer.
Q: How can I initiate an external review?
A: To initiate an external review, contact your healthcare coverage provider.
Q: Can I request an external review of any denied claim?
A: No. You may request an external review of a denied claim when:
- The insurance company has determined the service you want is not medically necessary, is experimental or is investigational
- Your provider documents that the service (and all care related to the service) will cost you more than $500 if not covered in the case of a medical necessity decision; and
- You request external review within 180 days of being notified about the internal decision.
Q: How long will it take for the external review to be performed?
A: The IRO must make its decision within 30 days. Decisions must be expedited within seven days if the health condition requires it.
Q: Can I appeal the IROs’ decision if I am not happy with it?
A: Decisions made by the IRO are final and legally binding.
Q: What are the common benefits of using an IRO?
A:
- Reduced liability through the utilization of external, Board Certified Specialists in the same or similar field of service as the original provider(s)*
- Reduced liability through the development of standardized medical criteria for prior authorization*.
- Improved member satisfaction through provision of an unbiased, evidenced-based external determination*.
- Ensured compliance with DOL/ERISA compliance guidelines*.
- Ensured compliance with state and federal mandates for appeals and medical necessity denials*.
To learn more about BHM’s URAC Accredited IRO services, or to schedule a demo of our Independent Review platform click below
Please find the original article at BHM Healthcare Soultions.
