Many payers and medical management companies have not discovered the power of outsourcing their medical decision making to an independent review organizationoften because theyve already assembled their own panel of internal doctors or using their own medical staff to make such decisions. Yet with rising state and federal regulations regarding the need for objective, unbiased decision based purely on medical fact, independent review organizations (IROs) offer a simple, easy alternative to other forms of medical decision making, including pre-authorizations that are critical for delivering high quality care according to patient needs. IROs play an important role in providing care in Americas health care system today. Over the last couple of decades, they evolved as a result of the patient rights movement. Patients increasingly demanded a fair hearing and a fair decision about whether or not they would be approved medical treatments. IROs filled that need. IROs began working by adjudicating and making decisions on medical claims in the government sector. Over the last several years, IROs have been utilized increasingly by mainstream health plans and others making such determinations. IROs serve a vital role by advocating for the patient while making sure that each patient only receives the care they deserve based upon medical fact. Bottom line, IROs eliminate wasteful and unnecessary treatments. If youre a medical management company or a payer, outsourcing to an IRO is a great way to assure that you make fact-based medical claims decisions and pre-authorizations every timeeven the most expensive and complex claims and treatments. IROs have mechanisms in place to provide decision making with a high degree of efficiency and at a very low cost. A good IRO has a full time recruiting and credentialing function that builds and maintains a specialist panel with all types of physicians and sub-specialists, as well as allied health care professionals. By using its panel, an IRO can easily match each case with a like healthcare specialist to make independent and objective medical decisions. An Independent Review Organization often has a highly automated workflow for routing cases to those physicians, getting their determinations in an efficient manner and typing and producing the written reviews that substantiate the decision in each case. IROs amortize their costs across hundreds (if not thousands) of monthly cases. This advantageous to a payer or medical management firm that doesnt have similar case loads and therefore can not achieve the same economy of scale. If your organization still has not unlocked the power an Independent Review Organization for making claims decisions and pre-authorizations, consider outsourcing as a strategy for improving your quality of care for your patient and members. Independent Review Organizations deliver exceptional valuewith fast turn around times at low cost. |
