When cases are coming in by the wheelbarrow full, you have to sort through them and decide how to handle each one quickly. Routine cases are easy. But what about out-of-the-ordinary ones? Don´t they deserve more than a spot at the far corner of your desk? You can do something about them. Knowing what you should look for in your organization or a case file might trigger the use of an IRO to speed reviews and help clear your desk.
Here are nine hints / telltale signs that you might need the help of an IRO:
1. Your medical staff doesn´t have the specialist knowledge to rule on the case effectively. When you need access to a breadth and depth of medical expertise beyond what is available among your staff or extended network, consider calling in an IRO that has a broad range of specialist doctors.
2. The case involved has had a high rate of appeal. Using an IRO to decide cases based purely on medical need can reduce the number of appeals you see.
3. The case has a short, mandated deadline. An IRO is set up to meet faster turn around needs and knows the deadlines for various state and federal requirements, which can help you meet mandated deadlines.
4. You think the treatment is experimental. IROs use specialist doctors who are current with the latest approved treatments and can tell you whether a treatment is experimental or has moved to the treatment mainstream.
5. The cases are piling up on your desk. Or they are not coming back from your internal medical staff quickly enough. This suggests that you might want to consider using an IRO to handle the tough cases to get your group caught up.
6. You find the claim suspicious. Whenever you have a claim that appears questionable, an IRO can help you find the holes so you can request suitable documentation or tests before moving the case on to more expensive treatments. IROs can review a patient´s case to discover if treating doctors meet all the necessary processes leading up to a proposed procedure and whether the patient needs the medical procedure recommended.
7. You´re facing a tough case. Maybe the cost of the claim or treatment is high. If so, you might want an IRO to review it before deciding the case. An IRO doctor decides the case based on the medical facts.
8. You think the case might involve a conflict of interest. You may need a buffer from any real or perceived conflict of interest that could result in a case appeal or legal action. IROs have no relationship with the organization, the doctor or the patient and provide decisions based solely on the latest medical facts.
9. You think cases are being rejected because of financial pressure to reduce costs. IROs decide cases based on the medical facts. Not being part of your organization, they are not influenced by cost-cutting pressure and the economic goals of your organization.
Using an IRO is an efficient and defensible way to manage a health plan properly for both the insurer and the patient. As unbiased advocates for managing healthcare costs, IROs ensure that every claimant is properly served, every time.
Based on our own internal studies, healthcare providers can save about $17 for every dollar they spend on outsourcing case reviews to an IRO. As an independent third-party, an IRO isn´t influenced by your organization´s financial goals or internal politics. They decide cases based on medical fact and within the time frame required by state and federal mandates.
About AllMed Healthcare Management
Founded in 1995, AllMed is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed's growing customer base for its independent medical review and hospital peer review services includes premier organizations, such as Educator's Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers. Read the AllMed Medical News Blog and the Independent Review Organization Blog .