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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 d
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SOURCE AllMed Healthcare Management
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