Clear communication is essential in many facets of life. Whether it’s a teacher telling students about classroom rules or a physician explaining a diagnosis to a patient, providing easy-to-understand direction is important. This need for clear and open communication is evident in the healthcare industry because it can make the difference in outcomes, patient safety, clinical decision-making and medication adherence.
Such transparency may also help reduce operating costs and improve productivity and patient satisfaction. Research notes that improving both market incentives and healthcare productivity could lower annual national health expenditures by $284-532 billion.
Clear and Conspicuous
Conspicuousness is one of the attributes that makes the use of independent review organizations (IROs) a high priority for many health plan payers, hospitals, state and local governments, pharmacy benefit companies and more. IROs utilize evidence-based reporting along with clinical research, regulatory requirements and practice guidelines to support their unbiased decision-making. They tailor the review process to meet the needs of each client to ensure the highest quality assurance and clinical accuracy. By providing decisions about medical care that are based solely on medical evidence, they act as a reliable and neutral resource with an extensive and specialized knowledge of healthcare services.
In addition to employing evidence-based reporting to deliver high-quality results to clients, IROs use physician matching to ensure reviews are conducted by specialty- and state- matched physicians. They are able to adhere to strict compliance requirements, deliver quicker turnaround times and meet the appropriate state and federal guidelines and recommendations.
A study by the American Association of Health Plans (AAHP) found that independent medical reviews had a positive influence on health plans’ internal review processes, such as accelerating the time frames for review and bringing in more external specialists for reviews of complex cases. Other substantiated benefits of independent medical reviews include patient protection, cost-effectiveness, improved health plan review process and reduction of costly litigation.
More benefits of using an IRO, as outlined by the National Association of Independent Review Organizations (NAIRO), include:
- Reduced liability through the utilization of external, board-certified specialists in the same field of service as the original provider.
- 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.
IROs often are tasked with conducting medical reviews on experimental and investigational services and/or procedures. For these cases, they must adhere to evidence-based standards from NAIRO, including:
- Licensed, credentialed and active clinical reviewers. IROs have immediate access to physicians and allied health care practitioners who are at the vanguard of medical treatments and services. These physicians are active in medical practice and stay up-to-date on the latest evidence-based studies and services in their field of specialty.
- Decisions that are supported by the latest evidence in medical literature. Clinical reviewers are considered experts in their field, and many IRO reviewers are affiliated with or have relationships with medical centers of excellence and research hospitals, linking them to the latest knowledge and resources of accepted medical practices and treatments. After reviewing a case, IRO-written determinations and rationales are supported with references from medical research literature.
- Advanced, ongoing education. The rigorous credentialing and reviewer programs for IROs are designed to ensure access to reviewers who are knowledgeable about the most current evidence-based medicine.
The benefits achieved through independent medical reviews aren’t confined to only those organizations who employ the services of an IRO. These reviews benefit the healthcare industry by improving productivity, increasing patient safety and further securing the rights of patients.
To learn more about Advanced Medical Reviews and explore how we can partner with you for your evidence-based reviews, visit the AMR website.