Getting the Most Out of Your IRO (Independent Review Organization)

Working with an Independent Review Organization (IRO) is a bit like working with your physician. How do you know you’re going to get the treatment to fix your ailment? Is the treatment covered by my insurance? How long do I have to wait for treatment? Have I given the doctor all of the information he or she needs to make the right care decision?
When requesting an independent medical review, careful consideration needs to be given to focusing on the specific issue(s) you’re trying to resolve. Understanding what questions to ask in the first place will help keep costs at a minimum by ensuring your IRO is reviewing the proper records and facts and correctly delivering decisions on the issues at hand – the first time.
It’s easy to confuse the issue of medical necessity of a procedure with the issue of whether or not a patient qualifies for that procedure according to your plan language. For example, say Mary Smith’s doctor has referred her to a chiropractor for back pain treatment but the plan language on her policy does not cover chiropractic services – no exceptions. Regardless of medical necessity or the doctor’s referral, the treatment would and should be denied. The IRO reviewer must be informed as to which issue you are trying to address up front.
Experimental and investigation treatments also pose a problem. Given constantly evolving technology, drugs and treatment protocols, it’s often difficult to keep up with what’s been approved as scientifically accepted treatment by the medical community and what’s still considered experimental procedure. Knowing that the plan exclusions always take precedence over inclusions can save a lot of time in the review process. The plan language definition of experimental/investigational is central to the decision.
Following are some tips designed to make it easier for you to work with your IRO and ensure meaningful outcomes for both the patients and your business every time:
Make sure you isolate the specific issue you are trying to address before you develop your questions, such as standard of care, medical necessity, experimental/investigational and/or plan language interpretation.
Develop a list of questions that must be answered with a definitive and substantiated reason.
Make sure you include all relevant chart documents and plan language that are needed to provide a definitive response.
If you have exhausted your efforts to get the records you need for a review, a “no” response from your IRO may be just the stimulus needed to prompt the record holder to release the full documents.
Understand that it’s your IRO’s responsibility to call with questions or clarifications on independent medical review requests before they begin. Make sure your IRO understands who to call and the best time of day that person can be reached.