NAIRO has released an important white paper that explains how health plans and TPAs should interpret the new health reform regulations as it relates to managing internal and external appeals. You can download it here:http://nairo.org/_pdf/uploads/nairo_appeals_whitepaper.pdf
This article provides a good overview of the external appeal review process. NAIRO members serve on external appeals panels in all states where such regulations are in place. The external appeals process is one more example of how IROs help to enhance and preserve the integrity of healthcare.
This article provides an excellent overview of strategies and tactics that consumers can pursue to appeal a denied healthcare claim. While not mentioned by name in this article, Independent Review Organizations (IROs) play a critical role in the appeals process for most health insurance carriers, as well as for most self-insured organizations. IROs typically review most consumer appeals. If you are appealing a claim with your insurance provider, we suggest that you ask them what the independent medical review process is and when an IRO will be involved.http://www.nytimes.com/2010/02/06/health/06patient.html?pagewanted=1&ref=health
NAIRO has recently written to President Obama, members and Congress and senior healthcare administration officials, to advocate for an increased role for Independent Review Organizations, as they consider improvements in our nation’s healthcare system. You can download a copy of the letter by clicking here.
As the new administration moves forward with its thinking on overhauling our healthcare system, we believe that Independent Review Organizations have a unique role to play in improving the integrity of healthcare delivery in the U.S. Leading payer and hospital organzations use IROs to review member appeals, quality of care issues and provide other services that protect consumers while reducing overutilitation. NAIRO members represent the leading IROs in U.S. healthcare today.
Independent Review Organizations Poised to Help Reduce Rising Healthcare Cost
LANSDALE, Pa., Feb. 4 /PRNewswire/ — According to the National Coalition on Health Care, the increasing cost of health care outstrips both wages and inflation. Each year premiums rise at almost double-digit rates. If this continues, healthcare costs will rise from five percent of the GNP to 13 percent by 2050.
Within the healthcare industry, independent review organizations (IROs) offer hope for reducing healthcare costs. IROs act as third-party medical review resources providing unbiased medical opinions to support effective decision making for health plans and other payers. Basing decisions on medical evidence and the detailed facts in each case, IROs deliver conflict-free decisions that help clinical and claims managers allocate healthcare resources better and reduce waste.
“We believe IROs play a key role in reducing healthcare costs,” said
Joyce Muller, NAIRO president. “While they are little known, IROs exist to assure that people paying for health care get what they’ve paid for and health insurers only pay for medically necessary treatments.”
This election year candidates from both parties are proposing solutions to the healthcare problem. “Greater attention is focused on keeping the escalating costs of healthcare down, and the effective use of IRO’s contribute to that,” Muller said.
IROs can help health plan providers and payers reduce costs by assisting with decisions like these:
- Ensure compliance with state mandates for appeals and medical necessity denials
- Help payers meet Dept. of Labor (DOL) and Employee Retirement Income Security Act of 1974 (ERISA) compliance guidelines
- Determine when a treatment is needed medically
- Decide whether a treatment is experimental based on the latest medical literature
- Decide if health plan language is outdated or ambiguous
- Investigate fraudulent claims
- Explore patient safety and quality-of-care issues
- Reduce liability by using external, board-certified doctors in the same field as original providers
- Help payers standardize medical criteria for pre-authorization
- Improve member satisfaction by providing unbiased, external opinions
- Eliminate conflict-of-interest concerns
Formed in 2000, NAIRO works to promote the value and integrity of the independent medical review process, as a key part of the solution to America’s healthcare crisis. Its members embrace an evidence-based approach to independent medical review to resolve coverage disputes between enrollees and their health plans. For more information visit http://www.nairo.org.
This article provides a good overview of the how the independent review process can improve physician performance, quality and patient safety in hospital settings. Many NAIRO members are involved in providing external peer review services to leading hospitals and ASCs.
If you are a consumer and have been denied coverage of a benefit by your health insurer, it’s important to know what your options are for appeal. This recent article in the Wall Street Journal sheds some light on the subject:
One thing the article does not point out, is that many leading health insurance carriers rely on Independent Review Organizations (including NAIRO members) to review all member appeals when benefits are denied. This is increasingly an industry best practice, and ensures the member a fair, evidence-based review of their claim.
If you are denied a benefit as a healthcare plan subscriber, it makes sense to learn the details of your health plan’s appeals policy. Specifically, you should ask whether or not your case will be reviewed by an IRO.
Here’s an updated version of AHIP’s periodic report which analyzes state external review programs:
External review is currently mandated in 44 states and is usually the final recourse for a health plan member who has been denied coverage and has exhausted the internal appeals process with his/her health plan. Most of these programs are administered by state insurance commissioner offices. The actual reviews are performed by independent review organizations (IROs), such as the members of NAIRO.
In addition to the external review programs highlighted in this document, it’s important to note that most leading health insurance payers employ the services of IROs to handle their internal member appeals. This is due to ERISA and Department of Labor regulations that require health plans to seek seek an evidence-based determination from an organization that is free from conflict of interest.
Today, NAIRO members power the health care decision making process for payers across the country, and are helping to raise the quality and integrity of our health care delivery system.
|Michigan’s Health Insurance Independent Review At Two Years Contact: OFIS (Toll-Free) 1- 877-999-6442
Agency: Financial and Insurance Services
In speaking with a representative at OFIS, the numbers now are comparable to the numbers in 2002. I don’t believe MI is alone in this. In speaking to other IROs they are facing this same issue. Why is this and what can we do to change this?