Getting The Most Out Of Your IRO

Friday, May 12th, 2017

There are many advantages to sending your medical reviews to an Independent Review Organization (IRO), from faster turnaround times to accessing more specialty knowledge. Once you have made the decision to use an IRO, it is important to have an understanding of how to get the best results. The following tips can help you get the most out of your IRO.

Identify the specific issue

When you request an IRO review, give plenty of thought to the specific issue you are trying to resolve. Know the right questions to ask up front and make sure that the IRO has the correct records from the beginning of the process. It is crucial that the IRO knows exactly what issue you are trying to address from the start.

Beware of confusing the issue of medical necessity with the issue of whether the procedure is covered based on your plan language. While the patient may need a certain treatment, if the plan does not cover that treatment it will be denied, regardless of necessity or doctor’s referral. Make sure to also include all relevant documents, including charts, and contract language that will be needed to provide a definitive response.

Understanding the contract language

Having a clear understanding of review standard, including contract language, is important for getting the most out of your IRO. You must also understand policy and guidelines, as well as standard of care.

Contract language typically defines care as either medically necessary, or experimental and investigational. The language may not be specific to a particular plan of treatment or procedure. However, contracts can be language specific to certain services such as fertility, obesity, or therapy. It can be difficult to keep up with what has been scientifically accepted by the medical community and what is still considered an experimental procedure. The contract language referring to experimental or investigational procedures is the key factor in the review decision.

Make your questions specific

Be as specific as possible in your questions to help make sure your review will be as effective as possible. Use specific language so that the IRO can focus exactly on what issue is in question. List the exact level of care that is under review. If you need specific information, ask questions that are as detailed as possible to obtain the information. It is also helpful to include the dates which define the period under review.

Healthcare providers must understand the review process, especially if they are to get the most benefit from an IRO. If you are in need of legal assistance regarding IROs and the healthcare industry, call the attorneys at Brown & Fortunato in Amarillo, Texas. You can reach 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.

This information is subject to change. Please check for updates that are more recent than the published date of this article.