Navigation Links
External Evidence-Based Reviews Keep Healthcare System Vital

IROs Balance Health Organizations, Consumer Interests

Westerville, OH (PRWEB) October 14, 2009 -- IROs exist to help the integrity of the healthcare system says NAIRO (, a trade organization of independent review organizations (IROs).

"As an objective participant in the healthcare process, IRO physicians can deliver determinations based on objective medical evidence, which helps preserve the integrity and quality of our healthcare system," said Seana Ferris, President of NAIRO. "All IROs use independent, board-certified physicians in active practice to make medical care determinations. We employ top specialists in their fields to help healthcare organizations make well informed determinations based on the latest medical literature and techniques available."

Unbiased Determinations
Not bound to health plans, plan administrators, patients or physicians, IROs ( increase the integrity of our healthcare system by assessing the merits of treatment based on clinical evidence and the accepted standard of care. IROs and their expert reviewers have no conflict of interest, because they are not associated with the patient, the patient's physician, the treatment, the health plan or the plan administrator seeking a review.

Evidence-based Reviews
IROs provide health insurance payers, pharmacy benefit managers, insurance carriers, hospitals and ambulatory centers (ASCs) with unbiased and evidence-based reviews of health insurance claims, patient claims and physician performance.

IROs work with various insurance payers, including carriers, reinsurers, medical management organizations, managed care organizations and third-party administrators (TPAs). For these, they provide independent evidence-based reviews that help utilization review, utilization and case management professionals to make fast, accurate decisions, across all medical specialties and sub-specialties. These include pre-authorizations, concurrent review of in-patient treatments and retrospective reviews of initial claims and member appeals.

For pharmacy benefit managers, IROs provide objective, independent drug utilization review (DUR) services that help them meet their cost containment initiatives, while ensuring the integrity of the drug benefits they offer their members.

For hospitals and ASCs, IROs provide external peer reviews that improve physician accountability and performance by supplementing their internal credentialing and peer review processes.

For workers compensation, life, disability, property and casualty insurance carriers, IROs provide medical review determinations critical to their claims and appeals process.

Payer Reviews
Payers often turn to IROs to review appeals denied reimbursement for healthcare services for healthcare providers ( This service improves the provider's relations with plan subscribers because it offers an unbiased means for evaluating disputed claims. Among the types of reviews, IROs conduct for payers are:

Medical necessity reviews may be voluntary or mandated by law.

Drug utilization reviews examine case records, applying a payer's formulary and the latest clinical evidence to determine coverage objectively

Utilization review is used by managed care plans and medical management organizations to control and reduce unneeded medical services. IROs provide the specialist expertise to UR organizations that power their decision making for pre-authorization of treatments, length of hospital stay and more.

Medical fraud reviews help insurance payer special investigation units (SIUs) law enforcement agencies and service providers detect and prevent provider and claimant fraud, while saving the healthcare system money and time.

Disability reviews consider the reasonableness of a disability claim based on the medical evidence, the extent of the injury, whether the claimant can perform work and the appropriateness of rehabilitation treatment.

State level Independent medical reviews normally occur after all appeals mechanisms available within a health benefits plan are exhausted.

Rescission appeal reviews retroactively evaluate eligibility for health care coverage based on any misrepresentation of a pre-existing condition or medical history on an insurance application. IROs assure unbiased consideration for the review of the member's appeal.

Provider Reviews
Providers benefit from independent reviews because they are unbiased and provide an objective perspective of physician performance.

Hospital external peer reviews help hospitals and clinics evaluate ongoing physician performance, practitioner performance during sentinel events and practitioner credentialing and privileging to assure excellence in physician performance and deliver the highest quality of patient care.

Imaging reviews for hospitals and clinics completed by IROs help monitor the quality of hospital or clinic radiology services by reviewing images produced by computerized axial tomography (CAT or CT), positron emission tomography (PET) scans and X-rays. Imaging reviews determine whether the original physician's interpretation of the images was correct and the standard of care was met.

How IROs Help the Healthcare System
As an intermediary between health providers' plans and subscribers, IROs can balance fairly and objectively the needs of both at the same time assuring standards-based processes are followed.
To improve healthcare quality for hospitals and clinics, IROs can assess physician performance and recommend physician education or suggest best practices for clinical departments. This reduces healthcare cost by evaluating the over utilization of medical treatments and drugs that aren't medically necessary. This reduces costs to all, while improving the quality of care.

"Because we are external to healthcare organizations, insurance carriers and payers, NAIRO member companies improve the integrity of healthcare by removing the conflict of interest often associated with internal reviews and by issuing unbiased, evidence-based determinations," Ferris said.

NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit


Read the full story at

Source: PRWeb
Copyright©2009 Vocus, Inc.
All rights reserved

Related medicine news :

1. Elpac Power System Extends Energy Star Portfolio with 65-Watt External Power Supply
2. URAC Seeks Public Input on New Uniform External Review Standards for Health Plan and Health Utilization Management Organizations
3. External beam partial breast irradiation most cost-effective treatment
4. External focus improves postural stability in patients with Parkinsons disease
5. Edmond Scientific Company Awarded VA Contract for External Integration Architecture Support
6. Elpac Power System 150-Watt Commercial External Power Supply Features Industry-Leading Efficiency and Power Density
7. Study Stresses Importance of Availability of Automated External Defibrillators at Athletic Events
8. Launches the First “External Prostate Massager” by Enviromax, a Sensational Way to Help Millions of Men Have Healthier Prostate Glands
9. $3.5 Million in Reimbursements for Purchases of Automated External Defibrillators (AEDs) for Texas Schools Still Unclaimed With Deadline Approaching
10. New Technique Removes Gallbladder Without External Incisions
11. Gallbladder removed without external incisions
Post Your Comments:
(Date:10/10/2015)... ... October 10, 2015 , ... Isabel Healthcare will participate in the Cerner Health ... the release of the Institute of Medicine’s latest report “Improving Diagnosis in Healthcare”, Isabel ... that assist healthcare providers and consumers to potentially reduce the chance of error. The ...
(Date:10/10/2015)... ... October 10, 2015 , ... In the inaugural people’s choice contest, entitled ... To Work in Jacksonville, amongst medium-sized companies with 25 – 99 employees. The announcement ... with a celebratory gala on October 1st. , Many of the features of ...
(Date:10/9/2015)... California (PRWEB) , ... October 09, 2015 , ... ... Osteopathic Medicine of the Pacific Associate Dean for Graduate Medical Education J. Michael ... of the Year Award. Finley was selected for his impact on graduate medical ...
(Date:10/9/2015)... Los Angeles, CA (PRWEB) , ... October 09, 2015 , ... ... awareness for breast cancer victims, survivors, and the ongoing effort to find a cure. ... patients another outlet for helping women in need. With their Bra Collection Campaign, Beverly ...
(Date:10/9/2015)... ... October 09, 2015 , ... A new health tool that helps identify if ... online ( ) – just in time for the cold and flu season, ... However, for many in the U.S., the real start of cold/flu season is the ...
Breaking Medicine News(10 mins):
... ... medical journal Osteoporosis International found that women taking AdvaCAL® calcium had the highest bone ... 32 studies involved 3,169 postmenopausal women, 79 skeletal measures and 7 different types of ... ...
... ... Dermatologist settled in Dubai, received the very prestigious ,HIND RATTAN AWARD, this ... Rattan was presented at a ceremony in connection with the yearly International ... Heavy Industries and Public Enterprises, Government of India. Dr. Mehta was awarded ...
... ... IL based management consulting and technology firm, today announced it will merge ... Gold Certified Partner, effective January 1, 2010. Logan Consulting is ... America, Europe and Asia since 1992. Under the new structure, ...
... , ... Omnetics Connector Corporation, the leading manufacturer of miniature high-rel connectors, is utilizing their ... , ... MN (Vocus) January 29, 2010 -- Omnetics Connector Corporation, the leading manufacturer of ...
... ... Vemma Nutrition Company launches Vemma ... or other sports drinks, Vemma THIRST goes beyond hydration by ... minerals, while replenishing the body with necessary electrolytes, specialized carbohydrates ...
... , , Majority of Mississippi ... Jan. 28 The following is a statement by ... Consumer Healthcare Products Association (CHPA): , "Today, the Mississippi ... that, if it becomes law, will greatly limit how cold and ...
Cached Medicine News:
(Date:10/8/2015)... , Oct. 8, 2015  Ardelyx, Inc. ... focused on gastrointestinal and cardio-renal diseases, today announced ... candidate, tenapanor, will be presented at the 2015 ... findings will include measures of sustained response in ... blind, placebo-controlled, randomized Phase 2 trial. The meeting ...
(Date:10/8/2015)...  Trovagene, Inc., (NASDAQ:   TROV) a developer ... of results from a field experience analysis featuring ... (PCM) platform to accurately identify mutational status, ... appropriate therapy for patients. Mark Erlander , ... the results today in an oral presentation titled ...
(Date:10/8/2015)... Oct. 8, 2015  Following months of investigation, Ross ... the nation alleging that the anticoagulant Xarelto,s recommended dosage doesn,t ... Philadelphia on behalf of a ... stroke because the drug didn,t work as the manufacturer suggested. ... other suits shortly on behalf of clients from across the ...
Breaking Medicine Technology:
... /PRNewswire/ --,Pieris AG, a bio-pharmaceutical company ... human protein therapeutics, announced today,that its ... targeting potential. , Commenting on this ... and Preclinical Development of Pieris said: ...
... NJ (June 21, 2007) Nymox Pharmaceutical,Corporation (NASDAQ: ... Company’s recently completed studies of NX-1207 for,benign ... a series of,upcoming U.S. urology meetings, beginning ... Association Meeting in Colorado,Springs. These independent podium ...
Cached Medicine Technology:
... reference laboratory and a worldwide leader in ... an extensive test menu of highly complex ... anatomic pathology. Owned by the University of ... half of the nation's university teaching hospitals ...
... is a national reference laboratory and a ... development. ARUP offers an extensive test menu ... in clinical and anatomic pathology. Owned by ... include more than half of the nation's ...
... ARUP Laboratories is a national reference ... laboratory research and development. ARUP offers an ... unique medical tests in clinical and anatomic ... ARUP Laboratories' clients include more than half ...
... a national reference laboratory and a worldwide ... ARUP offers an extensive test menu of ... clinical and anatomic pathology. Owned by the ... more than half of the nation's university ...
Medicine Products: