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IROs Help Cut Health Payers' Costs and Improve Image
Date:2/26/2009

ment under appeal.

Because payers cannot employ every "same-kind" specialist needed to review subscribers' appeals as federal and state laws require, they can incorrectly approve or deny the appeal based on inadequate knowledge. This undercuts their profitability and consistency of coverage determinations.

Improving coverage policy accuracy

Although ERISA, Department of Labor and most state regulations call for independent review of appeals, many payers are handling appeals internally to save costs. But, this practice may increase their costs and raise the potential for litigation based on member-perceived conflict of interest. Evidence-based evaluations by IROs support these laws and can reduce the chance of paying questionable or unnecessary claims, while providing a more defensible, evidence-based determination that decreases re-examining cases that have been appealed.

Using an IRO, payers can avoid setting unwanted precedents for controversial coverage of complex and critical claims. An IRO review using up-to-date coverage policies allows payers to quickly and accurately approve or deny medical treatments. By supporting their coverage policies with current medical evidence and standards of care, they reduce unnecessary appeals and lawsuits.

Increasing subscriber good will

During a recession, payers should carefully consider the hidden costs incurred by reviewing appeals internally with the cost of using an IRO. Independent medical reviews by IROs ensure subscribers receive their coverage benefits without administrative delay, while providing objective support for payers.

"Research by some of our members shows a return on investment of $15 to $20 for each dollar spent on appeals reviewed by the IRO," Muller said. "Unbiased medical reviews also improve good will between payers and subscribers, increase enrollments and reduce litigati
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SOURCE NAIRO
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