Navigation Links
Independent Review Organizations Take Pressure Off Healthcare Payers as Recession Deepens
Date:2/26/2009

IROs Help Ease Staff Burden, Maintain Compliance and Make Patient Safety a Priority

PORTLAND, Ore., Feb. 26 /PRNewswire/ -- The deepening U.S. economic recession has healthcare payers caught between member demands for better coverage and the need to reduce costs, while they also wrestle with business restructuring, declining budgets and staff cuts. Amid this, the expense and complexity of new technologies, treatments and drugs continues to rise.

"During this recession, payer organizations are servicing claims with fewer personnel, while new treatments and drugs continue to add complexity to them," said Andrew Rowe, CEO at AllMed Healthcare Management (www.allmedmd.com), a leading independent review organization (IRO). "Even with fewer in-house staff, payers can still offer high quality care, by outsourcing their more complex and critical claims and appeals decisions to an IRO," he explained.

Payer appeals departments often use IROs for evaluating the medical necessity of denied claims. These reviews meet ERISA and Department of Labor federal regulations, as well as most state requirements calling for an independent evaluation by a specialist who was not involved in the original coverage determination. "Although compliance is important to payers, forward-thinking health plans also use IROs to improve transparency and objectivity, which boosts their members' and groups' confidence," Rowe said.

Because they staff medical peer review specialists who objectively review healthcare claims for medical necessity, IROs help payers make determinations on their most complex and critical claims. "This ensures patients get the coverage they deserve, while eliminating unneeded treatments and costs," Rowe said. Organ transplants, oncology treatments, growth hormone therapy and bariatric surgery are a few examples of the types of cases IROs evaluate every day for leading payers.

Over-utilization and increasing pressure for reimbursements from providers compel health insurers to look closely at provider billing practices. "An IRO can help payers arbitrate provider appeals uniformly by determining the medical necessity of complex treatments and their associated coding," Rowe said. This especially helps health plans that are party to the Thomas Love Settlement, as well as others interested in identifying and questioning costly or suspicious reimbursements. Many times, the only way to deliver a fair, evidence-based determination is through a medical specialty review.

With today's constantly evolving medical policy and health plan language, payers need access to the specialized medical expertise that IROs offer to review and update their existing health plan language. This protects the health plan from over-utilization while ensuring that members receive the treatment they deserve.

Many health plans use peer review panels for conducting hearings and reviewing member and provider grievances and appeals. IROs with medical directors and peer specialty reviewers regularly engage in these review proceedings to provide objectivity and fairness for all parties.

IROs offer an effective outsourcing solution that helps payers manage costs, without compromising the need to make evidence-based coverage determinations. This is especially important as healthcare insurers and medical management organizations trim staff and expenses. "More than ever, payers need to take a hard look at what their core strengths are and focus on those," Rowe said. "Payers should consider outsourcing their complex member and provider appeals to gain evidence-based determinations conducted by like specialists that raise their members' confidence and contain their costs."

Find more information about the medical necessity review services offered by IROs on AllMed's web site at www.allmedmd.com.


'/>"/>
SOURCE AllMed Healthcare Management
Copyright©2009 PR Newswire.
All rights reserved

Related medicine news :

1. Sysmex Customer Satisfaction Ranks Highest in Independent Market Research
2. Privacy Watchdog Condemns Google for Effort to Defund it: Calls for Greater Corporate Disclosure About Lobbying Efforts and Independent Privacy Chief
3. WellPoint Joins New York Attorney General in Creation of New Independent Database for Out-of-Network Reimbursement
4. Innophos Holdings, Inc. Elects John M. Steitz as New Independent Director
5. NHP Names New Chairman and Lead Independent Director
6. Former Assistant Secretary for Aging, The Honorable Josefina G. Carbonell, Appointed Senior Vice President at Independent Living Systems
7. Alaska Governor Sarah Palin Is Independent Group Home Living Foundations Honoree of the Year 09
8. Sleep disordered breathing and obesity: Independent effects, causes
9. HPS Establishes Independent Website for its Patent-Pending Mood-Enhancing Compound Naturally Found in Sea Coral
10. Renhuang Pharmaceuticals, Inc. Engages New Independent Auditor
11. Independent Audit of Global Child Immunizations Urged
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:10/13/2017)... ... October 13, 2017 , ... Lori R. Somekh, founder of the ... a national organization of elder law and special needs planning attorneys. “Membership in ElderCounsel ... also provides a forum to network with elder law attorneys nationwide,” said Somekh. ...
(Date:10/13/2017)... ... October 13, 2017 , ... Global Healthcare Management’s 4th ... Park in Milford, NJ. This free event, sponsored by Global Healthcare Management’s CEO, ... The fun run is geared towards children of all ages; it is a non-competitive, ...
(Date:10/13/2017)... ... ... “America On The Brink”: the Christian history of the United States and the ... published author, William Nowers. Captain Nowers and his wife, Millie, have six children, ... in the Navy. Following his career as a naval aviator and carrier pilot, ...
(Date:10/12/2017)... ... October 12, 2017 , ... IsoComforter, Inc. ( https://isocomforter.com ), one ... an innovative new design of the shoulder pad. The shoulder pad provides optimal ... controlling your pain while using cold therapy. By utilizing ice and water that is ...
(Date:10/12/2017)... , ... October 12, 2017 , ... HMP , ... recipient of a 2017 Folio Magazine Eddie Digital Award for ‘Best B-to-B Healthcare Website.’ ... on October 11, 2017. , The annual award competition recognizes editorial and design excellence ...
Breaking Medicine News(10 mins):
(Date:9/28/2017)... 28, 2017 Cohen Veterans Bioscience and Early ... of wearable and home sensors for real-time monitoring of ... Foundation, a nonprofit organization focused on disruptive health solutions ... affordable analytical system to record and integrate behavioral, cognitive, ... ...
(Date:9/27/2017)... and NEW YORK , Sept. 27, 2017 ... mobile health and big data solutions, today announced that its MyDario product ... check your local TV listings for when The Dr. Oz Show airs ... The ... this month. ...
(Date:9/25/2017)... , Sept. 25, 2017  EpiVax, Inc., ... vaccine design, and immune-engineering today announced the launch ... the development of personalized therapeutic cancer vaccines. EpiVax ... provided exclusive access to enabling technologies to the ... MBA will lead EpiVax Oncology as Chief Executive ...
Breaking Medicine Technology: