Justification for Using IRO
Increasingly, health care providers, insurers, and case managers are turning to IROs as as collaborative extension of their decision making process for claims. Reasons for this alliance may included:
Access to deep medical knowledge:
Case managers may need to access a breadth of medical expertise or to an outside source of medical expertise beyond what they have available among their staff or extended network.
Reduced concerns or partiality:
Case managers may need a buffer for their clinicians from any real or perceived conflict of interest. In claims that have potential high appeal rates or some risk factors, health plans providers and insurers may want an external, independent, an objective perspective regarding the claim so that that the results are not tainted by the potential bias of the physician on their payroll.
Validation of a decision:
Case managers need to ensure that the denial and or approval is the accepted science of medicine. . An IRO provides access to a physician with the same credentials as the one making the recommendation.
Improved responsive:
When mandated state and federal deadlines must be met, payers can use an IRO to expedite the review of a given case to ensure these deadlines are met each and every time.
Decreased cost:
Case managers organizations are under constant pressure to reduce cost. Outsourcing medical claims decision making to an IRO allows providers to reduce expensive physician overheads by paying only what they need, when they need it.
MMro’s Independent Review Advantage
- Highly experienced review team
- National review network
- Reliable, timely and quality reviews
- Reviews that are tailored to meet your organization’s needs
- Solid quality improvement foundation that ensures consistency of review processes and decisions