If as a utilization review or utilization management nurse or a case manager, your job is to pre-authorize complex claims and treatments, one thing that you can do to make your job easier is to outsource your most difficult cases to an Independent Review Organization. We work with hundreds of organizations across the United States that do this. They have found great benefit in terms of cost reduction, and speedier decision making when it comes to preauthorizing expensive or complex treatments. Managed care nurses typically have many years of health care experience. Often they have many years in clinical practice that’s also supplemented by years of case management reviewing many different types of cases and treatments.
Despite these years of experience, case management nurses and Utilization Review nurses cannot be expected be up to date on all the newest medical treatments and diagnoses. In fact, the standard of care continues to change. What was once viewed as a cosmetic treatment can now be diagnosed as medically necessary because those standards change.
This is why an Independent Review Organization is so important to a managed care nurse. What it allows you to do is extend your reach by allowing you to tap into the up to date knowledge of top specialist physicians across the country to make preauthorization decisions more effective. It’s widely considered a best practice today.
Some manage care organizations and medical management firms have their own panel of physicians, yet increasingly the best Managed Care Organizations and Utilization Review companies are outsourcing this function. Why? They can't compete with the services of an Independent Review Organization for cost, credentialing, availability or turn around.
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 .