8 Ways Independent Review Organizations Can Help You

Healthcare providers and insurance companies often turn to the assistance of Independent Review Organizations (IROs) to collaborate on reviewing medical claims. IROs are third-party entities that can assist healthcare providers and insurers in reviewing medical claims by providing unbiased determinations. Essentially, an IRO can provide an independent decision to help medical professionals properly manage their resources. If you are unsure about hiring an IRO, here are eight signs that may indicate you need one.

A case is highly specialized

Case managers need access to both breadth and depth of medical knowledge when reviewing complicated or sensitive medical claims. Since modern medicine is advancing at unprecedented rates, new disciplines are being developed and specialties are constantly changing.

Some claims deal with issues that are too complicated for a case manager to handle without help. IROs can provide specialized knowledge that a case manager may not have access to otherwise.

There is a risk of appeal

IROs provide unbiased, third-party reviews of medical claims. Therefore, if you are concerned about the risk of a claim or healthcare decision being appealed, including an analysis from an IRO avoids the appearance of relying on a consultation with a biased healthcare provider. Essentially, using an IRO can prevent a possible appeal, keeping down your costs.

You need an unbiased review

An unbiased review can also help healthcare providers whose decisions are being watched. Healthcare providers, despite their numerous internal checks, can still be influenced by self-interest. This can negatively affect any decision on large, complex, or questionable cases. IROs ensure that healthcare providers and insurers have a paper trail indicating unbiased review and determination in the event of an audit or litigation.

When you want to reduce costs

Internal specialized case managers can be expensive to hire, because you may only need their services a few times a year. You can significantly reduce costs by outsourcing complex reviews to IROs who provide services on an as needed basis. Using an IRO allows healthcare providers to more efficiently allocate their resources.

You think a case may be fraudulent

When you suspect a case is fraudulent, you should be careful to manage it within the scope of healthcare law. IROs can provide the unbiased, third-party review that you will need to confirm if the case is fraudulent. For example, an IRO can determine if the treating physician followed all procedures properly and adhered to accepted medical practices. They can also determine whether the patient actually needs the procedure or treatment in question or if the healthcare provider is being deceptive.

When there are deadlines to meet

Many payers are subject to state and federal deadlines to render decisions on medical claims. If your organization is unable to render decisions within these deadlines, you can hire an IRO in order to meet them.

Another issue related to meeting deadlines is streamlining the case review process. IROs that are brought in early on can introduce more efficient methods that speed up the review of medical claims and help prevent backlogs.

You want a conflict free review

IROs can provide a buffer against the appearance of a conflict of interest that can arise when healthcare providers can benefit financially from a decision to provide, or not provide, medical care. Lacking any financial motive, IROs ensure that decisions are made on an objective basis.

When a treatment is experimental

Experimental treatments are a complex matter for case managers to assess. Whether a medical claim is accepted or denied, the decision should be based on accepted science. Although some treatments and procedures are not well-known, they can still be supported by accepted science. IROs can provide the expertise to assess various experimental treatments and procedures so you do not have to spend resources researching them yourself.

If you need legal assistance with complicated medical claims or IROs, contact the Healthcare Attorneys at Brown & Fortunato, P.C. in Amarillo, Texas. You can call us at (806) 345-6300 or Contact Us by email for more information about our Practice Areas. You can also visit our offices at 905 S. Fillmore, Suite 400, in Amarillo to see how we can help you.