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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


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