NAIRO | Blog

Internal/External Appeals Explained by NAIRO

admin — Tue, 04 Jan 2011 16:31:29 +0000

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

How to Appeal a Health Claim Denial

admin — Thu, 17 Jun 2010 20:13:28 +0000

http://www.consumeraffairs.com/news04/2010/06/health_claim_denials.html

How to Appeal a Health Claim Denial

admin — Thu, 17 Jun 2010 20:11:19 +0000

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.

Fighting Denied Claims Requires Perseverance - NYT Article

admin — Tue, 16 Feb 2010 20:26:10 +0000

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

Letter to President Obama and Congress

Author — Fri, 20 Feb 2009 22:48:56 +0000

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.

Nairo’s president quoted in Resident and Staff Physician

Author — Fri, 26 Dec 2008 13:27:28 +0000

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

About NAIRO

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.

SOURCE NAIRO

Independent Review Supports Transparency

admin — Thu, 09 Oct 2008 19:10:57 +0000

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.

www.psqh.com/sepoct08/peer.html

Consumer Options When Denied Healthcare Coverage

Author — Fri, 26 Sep 2008 18:47:53 +0000

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:

http://online.wsj.com/article/SB122230334120773621.html

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.

AHIP’s published update on state external review programs for 2006

Author — Tue, 12 Aug 2008 23:59:22 +0000

Here’s an updated version of AHIP’s periodic report which analyzes state external review programs:

http://www.ahipresearch.org/PDFs/StateExternalReviewReport.pdf

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.

Comparison of MI IRO data in 2002 to current data

Author — Tue, 29 Jul 2008 17:41:39 +0000

Michigan’s Health Insurance Independent Review At Two Years Contact: OFIS (Toll-Free) 1- 877-999-6442
Agency: Financial and Insurance Services

November 6, 2002

The Michigan Patients Right to Independent Review Act (PRIRA) turned two years old on October 1, 2002. This act updated Michigan’s health maintenance organization (HMO) review process begun in 1978 and is administered by the Michigan Office of Financial and Insurance Services (OFIS). PRIRA has proven to be an efficient consumer protection measure for reviewing HMO and health insurance company denials.

“Michigan’s independent review of health insurers and HMOs denying coverage for treatment has provided consumers with independent decisions about whether the denial was fair,” said OFIS Commissioner Frank M. Fitzgerald. “The program benefits consumers by giving them with somewhere to turn for help.”

Since October 1, 2000, PRIRA has handled 665 cases. Of those cases, 355 cases are denials of coverage by Blue Cross Blue Shield of Michigan, 221 by HMOs, and the remaining 89 are commercial insurers and alternative financing delivery systems (AFDS). Additional detail for PRIRA case statistics can be reviewed on the OFIS web site at www.michigan.gov/documents/cis_ofis_compinfo_28032_7.html.

Use of the PRIRA process continues to grow. Forty-seven cases were handled during October through December 2000. For the calendar year 2001, PRIRA had 333 cases. Through September 20, 2002, PRIRA has handled 285 cases. OFIS is predicting that PRIRA will handle over 380 cases in 2002.

The PRIRA process has decided in favor of the consumer 44% of the time and upheld the coverage denial 56% of the time. This number is in line with the average experience of other states with an independent review process.

The most common medical procedures reviewed in the PRIRA process are bariatric surgery, breast reductions, dental crowns, physical therapy, and experimental procedures.

PRIRA consists of three simple steps:

First, at the time of the coverage denial, consumers receive information from the health insurance company or HMO about the health plan’s internal appeal process.
Second, if there is still a denial at the end of the internal appeal process, the health insurance company or HMO provides the consumer with PRIRA information.
Third, within 35 days of the consumer’s request for a PRIRA appeal, OFIS will provide a final decision on the denial. If consumers are not satisfied with the external review decision, the matter can be taken to court.

The PRIRA process also allows for an expedited review process. If a physician thinks that the coverage denial threatens the life of the consumer in any way, PRIRA can be completed within 72 hours.

“The data shows that the independent review process works,” commented Steve Gools, State Director, AARP/Michigan. “We need to make sure that Michigan citizens understand that they have this service available, and that it can help ensure that they receive fair treatment from insurers and HMOs. The state needs to continue letting people know about this process, and AARP is willing to help get out the word.”

The PRIRA process can be used for denials from health insurers, HMOs, Alternative Finance and Delivery Systems (AFDS), and Blue Cross/Blue Shield of Michigan (BCBSM). Medicare supplement, disability income, hospital indemnity, specified accident, credit, self-funded health plans, or long-term care insurance policies do not qualify for the external review process. If consumers have a policy that does not qualify for external review or do not know what type of policy they have, OFIS staff can direct consumers to the correct process and agency.

“The most important thing to know is if that if there is a complaint about a denial from a health insurance company, Blue Cross Blue Shield of Michigan, or an HMO – call OFIS toll free at 877-999-6442,” said Fitzgerald. “OFIS staff can explain the external review process and make sure consumers have the correct complaint process.”

On October 1, 2002, OFIS started posting PRIRA decisions electronically to the OFIS web site. The decisions do not contain any personal information and can be accessed at www.michigan.gov/ofis by following the “Hearing and Decisions” link from the left hand side of the page. The direct link is http://www.michigan.gov/cis/0,1607,7-154-10555_20594—,00.html. OFIS is posting current decisions and will be posting PRIRA decisions from October 1, 2000 through October 1, 2002 in the near future.

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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?