External Evidence-Based Reviews Keep Healthcare Sys...(rators (TPAs). For these they provide in...),Health

Date:10/14/2009

rators (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 (http://nairo.org/payors-find.php). 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
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