News & Events
The National Association of Independent Review Organizations (NAIRO) is actively involved in the issues surrounding the independent medical peer review industry. The following links provide an information source for recent and upcoming news and events concerning the NAIRO organization and its objectives.
Internal Reviews of Consumer Health Plan Appeals Tainted by Conflict of Interest Says NAIRO
Westerville, Ohio — July 12, 2010 — NAIRO, a trade organization of independent review organizations, says the Patient Protection and Affordable Care Act HR 3590 needs more regulatory control to protect consumers when health plans deny their coverage. A key part of the legislation, Section 2719, calls for health plans to impose effective internal and external appeal processes when they deny members coverage. Without further regulations that clarify these processes, the bill does not protect consumers against health plan conflict of interest.
Health Plan Appeals Conflicted
“Part of the intent of HR 3590 is to protect healthcare consumers by strengthening their appeals process,” said Seana Ferris, President of NAIRO. “But many health plans are compromised by conflict of interest, because they often use their own doctors to perform first and second level appeals of denials.”
Health Plan Doctors and Conflict of Interest
Health insurance plans using their own doctors to review member appeals is a conflict of interest, because these doctors are subject to the plan’s management directives, such as the need to cut or contain costs. By using internal physicians as reviewers, health plans can appear “denial driven” and more worried about finances than using the newest medical services and technologies to improve patient outcomes.
“NAIRO is concerned about potential and apparent conflict of interest in appeals,” said Ferris. “For the self-insured, ERISA and Department of Labor regulations specify an independent medical review of appeals to protect health plan members against unjustified denials of claims. These existing Federal and state regulations for self insured plans should also be enacted in the fully insured market.”
Third Parties Offer Objectivity
While many health plans continue to use their own doctors, some have reduced conflict of interest concerns by using independent review organizations (IROs) to review patient claim denials as a best practice. Others use IROs to provide suitable specialists for reviewing appealed cases.
“The intent of HR 3590 is well meaning,” Ferris said. “However, in its current form, it fails to state that internal appeals must avoid conflict of interest to assure health plan members get the treatment they paid for. We suggest doctors who practice the same or similar specialty and who are not on a health plan’s payroll, review appealed cases to decide them based solely on medical evidence.”
Consistent National Appeal Process
NAIRO proposes consistent national legislation requiring health plans to use independent doctors outside the health plan for internal reviews of appeals. The trade group believes IRO involvement would remove otherwise conflicted decision-making, promote evidence-based medical decision making and assure consumers receive the care they pay for.
“As federal regulators work to flesh out the details of Section 2719, we believe it’s critical for them to consider how to reduce the effects of conflict of interest on appeals,” Ferris said. “Requiring health plans to use independent third parties to review patient claims denials guarantees that all consumer appeals receive an objective, evidence-based review to preserve the integrity of the process.”
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process. Its members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
Health Plan Policy Rescission Won’t Go Away Says NAIRO
Westerville, Ohio — Feb. 24, 2010 — Regardless of the outcome of the national health care reform debate, consumers, health plans and state insurance commissioners will struggle over insurance policy rescission, says NAIRO, a national association of IROs.
Guarding Against Fraud
Health plans use insurance policy rescission — declaring an individual’s health plan contract invalid — to combat insurance fraud and intentional consumer misrepresentation. Usually these issues are not discovered by the health plan until an individual files a medical claim.
Unfortunately over the years, lawsuits and related investigations suggest some health plans have used rescission to invalidate insurance policies for pre-existing conditions, unintentional mistakes, omissions or simply missing checkboxes on complex insurance forms. Using a process termed “post-claims underwriting,” the health plan invokes a rescission clause in the contract. The clause claims policyholders have intentionally misrepresented their health status or the health issues “pre-existed” their enrollment allowing the insurer to cancel the policy.
“What is needed to address this issue is an unbiased independent rescission review process that meets both the needs of consumers and health plans,” said Seana Ferris, President of NAIRO.
AHIP Guidelines Support Third-party Reviews
America’s Health Insurance Plans (AHIP) and NAIRO support an unbiased approach to rescission review. Recently AHIP published rescission review guidelines calling for health plans to conduct an “objective and thorough investigation prior to initiating the rescission process” for any claim denied based on a pre-existing medical condition. The AHIP guidelines encourage regulators to screen rescissions to determine their eligibility for external review. They also advocate a third-party reviewer must be independent from both the health plan and the consumer to ensure fairness. The guidelines further suggest health plans create standards to ensure rescission review is consistently applied, and includes specific timeframes for completion and expediting reviews.
Consumer Options for Review
Many health plans are adopting the use of IROs to provide an objective review of a member’s appeal of a rescission determination. However, part of the burden of a rescission review remains on the policyholder. According to most health plans and the AHIP guidelines, consumers should first exhaust their plan’s internal appeal process before requesting a third-party review through their state’s insurance commissioner or office of consumer protection.
Consumers seeking to appeal their insurer’s decision to rescind their healthcare insurance have the right to an external appeal. Some of the steps they must take to request an external review include:
• Ask the health plan the specific reason for the policy rescission.
• Carefully read the insurance policy and make a list of questions about the rescission.
• Review the providers’ policy handbook to find the process time allotted for a rescission appeal request and confirm this with the health plan.
• Contact the state insurance commissioner to answer any questions needed to start an external review.
• Meet all external review related deadlines and ask questions along the way.
• Keep copies of correspondence, phone calls, documentation and medical records regarding the rescission review request.
Delivering Unbiased Determinations
As a best practice, many health plans are now enlisting IROs to review rescissions on a case-by-case basis using standardized guidelines and expert review of the medical facts.
“IRO objectivity is the reason state legislators in 45 states and the District of Columbia have mandated the independent review of healthcare appeals,” Ferris said. “Using an independent and unbiased third-party to review rescission is a best practice that preserves the quality and integrity of our healthcare system and the rescission process.”
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process. Its members embrace an independent, evidence-based approach to medical review to resolve coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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IROs Will Help Keep Costs in Line under Any Future Healthcare Scenario
Westerville, Ohio — November 20, 2009 — As Congress shapes the current draft of national healthcare reform legislation, government leaders continue debating whether its funding should be private, public or a mix of both. Regardless of the outcome of the legislation, a need still exists for independent review organizations (IROs) to ensure covered treatments are medically necessary and appropriate, says NAIRO, a national association of IROs.
“No matter the shape of healthcare reform, IROs will continue to provide the checks and balances that make sure payers cover the care that was contracted for and patients get the medical care to which they are entitled,” said Seana Ferris, President of NAIRO.
Playing an Objective Role
IROs are impartial third parties that play an important role in healthcare, because they deliver determinations based on standardized medical necessity guidelines, expert determinations or objective medical evidence. Their unbiased approach helps preserve both the quality and integrity of our healthcare system. For that reason, state legislators in 45 states plus the District of Columbia have mandated that IROs review healthcare appeals, Ferris pointed out.
Working with Diverse Groups
IROs work with a broad range of both payer and healthcare provider organizations, Ferris explained. On the payer side, IROs provide services to health plans, reinsurers, third-party administrators (TPAs), medical management organizations, benefit managers and insurance carriers. On the provider side, they work with hospitals and ambulatory surgery centers (ASCs). For all these organizations, IROs provide unbiased and evidence-based determinations for health insurance claims, disability and fraud claims, drug utilization reviews, preauthorization reviews, reviews of patient claims and reviews of physician performance. The medical review determinations IROs provide are critical to the proper execution of payer and patient claim and appeal processes, as well as ensuring the appropriate delivery of health care.
Because objective determinations from IROs may improve a provider’s relations with plan subscribers, payers often engage IROs to review denials of coverage for healthcare services in an effort to ensure their decision reflects the current medical standard of care.
Saving Payers and Patients
A March 2009 study, “Health Care Costs: A Primer,” reported that during 2007, the U.S. spent $2.2 trillion on health care — an average of $7,421 a person. Without IROs as a way to help control these rising healthcare expenses, this figure could well have been higher, Ferris noted. IROs have proven protocols in place to help contain these costs. “NAIRO member surveys show that for every dollar a health insurer spends on medical reviews, it saves at least $15 by eliminating unnecessary treatments,” she said. On the other hand, IROs play a critical role in upholding the rights of healthcare consumers, by ensuring they receive the benefits which are medically necessary and which are covered by their health plan.
Whatever comes out of the new healthcare legislation, IROs will continue to assure healthcare cost containment, as well as appropriate delivery of care. “With limited resources, we must look at the costs of any future healthcare scenarios,” Ferris said. “Regardless of the many potential scenarios, our industry demonstrates an outstanding return on investment today, and it stands ready to do so under any new healthcare legislation.”
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process. Its members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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External Evidence-based Reviews Keep Healthcare System Vital
IROs Balance Health Organizations, Consumer Interests
Westerville, Ohio — Oct. 14, 2009 — IROs exist to help the integrity of the healthcare system says NAIRO (www.nairo.org), a trade organization of independent review organizations (IROs).
“As an objective participant in the healthcare process, IRO physicians can deliver determinations based on objective medical evidence, which helps preserve the integrity and quality of our healthcare system,” said Seana Ferris, President of NAIRO. “All IROs use independent, board-certified physicians in active practice to make medical care determinations. We employ top specialists in their fields to help healthcare organizations make well informed determinations based on the latest medical literature and techniques available.”
Unbiased Determinations
Not bound to health plans, plan administrators, patients or physicians, IROs (http://nairo.org/what.php) increase the integrity of our healthcare system by assessing the merits of treatment based on clinical evidence and the accepted standard of care. IROs and their expert reviewers have no conflict of interest, because they are not associated with the patient, the patient’s physician, the treatment, the health plan or the plan administrator seeking a review.
Evidence-based Reviews
IROs provide health insurance payers, pharmacy benefit managers, insurance carriers, hospitals and ambulatory centers (ASCs) with unbiased and evidence-based reviews of health insurance claims, patient claims and physician performance.
IROs work with various insurance payers, including carriers, reinsurers, medical management organizations, managed care organizations and third-party administrators (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 more.
Medical fraud reviews help insurance payer special investigation units (SIUs) law enforcement agencies and service providers detect and prevent provider and claimant fraud, while saving the healthcare system money and time.
Disability reviews consider the reasonableness of a disability claim based on the medical evidence, the extent of the injury, whether the claimant can perform work and the appropriateness of rehabilitation treatment.
State level Independent medical reviews normally occur after all appeals mechanisms available within a health benefits plan are exhausted.
Rescission appeal reviews retroactively evaluate eligibility for health care coverage based on any misrepresentation of a pre-existing condition or medical history on an insurance application. IROs assure unbiased consideration for the review of the member’s appeal.
Provider Reviews
Providers benefit from independent reviews because they are unbiased and provide an objective perspective of physician performance.
Hospital external peer reviews help hospitals and clinics evaluate ongoing physician performance, practitioner performance during sentinel events and practitioner credentialing and privileging to assure excellence in physician performance and deliver the highest quality of patient care.
Imaging reviews for hospitals and clinics completed by IROs help monitor the quality of hospital or clinic radiology services by reviewing images produced by computerized axial tomography (CAT or CT), positron emission tomography (PET) scans and X-rays. Imaging reviews determine whether the original physician’s interpretation of the images was correct and the standard of care was met.
How IROs Help the Healthcare System
As an intermediary between health providers’ plans and subscribers, IROs can balance fairly and objectively the needs of both at the same time assuring standards-based processes are followed.
To improve healthcare quality for hospitals and clinics, IROs can assess physician performance and recommend physician education or suggest best practices for clinical departments. This reduces healthcare cost by evaluating the over utilization of medical treatments and drugs that aren’t medically necessary. This reduces costs to all, while improving the quality of care.
“Because we are external to healthcare organizations, insurance carriers and payers, NAIRO member companies improve the integrity of healthcare by removing the conflict of interest often associated with internal reviews and by issuing unbiased, evidence-based determinations,” Ferris said.
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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Patients Must Know Rights When Health Plans Deny Claims
State Legislation Provides Processes Protecting Patients’ Rights
Westerville, Ohio — Aug. 25, 2009 — Newspapers report daily that our healthcare system is broken, express concern about healthcare denials and mention that the system shifts costs to consumers. Commonly denied treatments include cosmetic surgeries, experimental/investigational drug therapies, pain management and chiropractic treatments according to NAIRO (www.nairo.org), a trade organization of independent review organizations (IROs). Health plans claim they deny such cases based on whether the treatment is medically necessary, in network, covered by the medical policy or experimental/investigational.
“State laws give patients denied payment of treatment or services recourse for appeal,” said Seana Ferris, President of NAIRO. “Unfortunately many healthcare consumers don’t understand the process, don’t know their right to appeal or quit too soon.” Presently 44 states and the District of Columbia have external review legislation. NAIRO provides frequently asked questions about patients’ rights on its Website at www.nairo.org/patients-faq.php.
Steps for Patient Appeal
By learning the steps in their health plan’s and state’s appeal processes, patients can escalate their appeal to appropriate agencies when necessary. “Patients denied payment of treatment must first exhaust the internal appeal process offered through their health plan,” Ferris said. “Following the denial of an internal appeal, they can request an external review using a qualified and unbiased third-party, like a URAC-accredited IRO.” Generally, the health plan, not the patient, bears the cost of an external review.
Ask Questions
To start the process, patients need to ask questions, like these:
• What is the reason for the denial?
• Did the health plan seek an independent medical review determination from an IRO before denying coverage?
• What are the timeframes to make an appeal and what information is required?
States Decide the Process
IROs assist many leading health plans in making medical necessity determinations as a part of the plan’s internal appeal process. Typically, this is a best practice among health insurers. However not all health plans conduct these arm’s length reviews. When a health plan denies a benefit, consumers should inquire whether the plan conducted an objective review using an unbiased third party, like an IRO.
Once patients exhaust the internal review process outlined by their health plan, their rights hang on the type of claim denied and the state they live in. Their next step is to request an external review appeal following the process established by their state insurance commissioner.
Role of the IRO
IROs employ independent, credentialed and licensed healthcare practitioners with specialist credentials needed to perform an evidence-based review a case based on its medical necessity. The expert is board-certified, in active practice and has the knowledge and experience to perform an unbiased and thorough medical review of the case.
“Consumers today have many rights when it comes to healthcare denials,” Ferris said. “They just need to learn the ins and outs of the appeal process and then see the process through to the end.”
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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Determining Insulin Pump Need for Diabetics
Health Plans Consult IROs to Balance Long-term Effects of Diabetes with Cost
Westerville, Ohio - July 28, 2009 - All doctors recommend diabetic patients control their glucose level, but how can they do this while preserving a normal lifestyle? By using an insulin pump and carbohydrate counting, a diabetic can maintain precise glycemic control and lessen the long-term effects of their disease. Still, because of the cost of insulin pumps and their supplies, health insurers often turn to independent review organizations (IROs) to decide their medical necessity.
"Using evidence-based criteria, IROs review the medical necessity of insulin pumps for health plans," said Seana Ferris, President of NAIRO, a trade organization of IROs. "They must weigh improved glycemic control, patient pump management, patient knowledge and lifestyle against the long-term cost of a diabetic's health care before approving a $6,000 pump that also requires hundreds of dollars a year for supplies."
When Insulin Pumps are Medically Necessary
Replacing injections, a pump delivers insulin 24-hours a day through a catheter under the skin. With a pump with carbohydrate counting, a patient can adjust insulin levels accurately for food intake and elevated or low blood sugar. "Health plans often cover pumps when they improve a patient's diabetic care and provide better control than multiple daily injections," said David Sand, M.D., Chief Medical Officer of an Ohio IRO, HMS-Permedion, and a pump-wearer. "They routinely cover pumps for patients with type-1 diabetes. The hope is that better glucose control lessens end-organ damage, which can benefit type-2 patients also."
Health plans may ask an IRO review the medical necessity for an insulin pump when daily doses of insulin don't achieve tight glycemic control and the hemoglobin A1c rises above the recommended seven percent set by the American Diabetes Association, or when hypoglycemia continues despite adjusting insulin doses. "Programming the pump to adjust basal insulin delivery rates and boluses throughout the day allows for more precise glycemic control, achievement of target HbA1c levels, and prevention of long-term complications," Sand said.
Demands Patient Skills
Sand explained that a concern of health plans about insulin pumps is the patient's ability to manage one. A healthcare provider team, including an endocrinologist and diabetes nurse educator, teaches the patient how to insert and change the catheter, set and adjust the basal rate and calculate boluses.
"While glucose monitoring is important for any diabetic, it's even more so for pump users who must adjust their boluses regularly for food intake and activity," Sand said. "Besides, pumps aren't an excuse for dietary indiscretion. Patients must learn carbohydrate counting to deliver correct insulin boluses at mealtimes."
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process, as an integral part of improving U.S. health care. Its members embrace an evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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NAIRO Announces Membership Drive
August 1, 2009
NAIRO is launching a membership drive, designed to broaden its base of participating IROs. For a limited time, our membership fee has been reduced to $500.
Membership benefits include the following:
•A direct line of communication with URAC senior management to raise issues and concerns as a group and to influence URAC application and modification of standards.
•A member on the URAC standards committee to express concerns and offer the viewpoint of NAIRO member organizations.
•Immediate and up-to-date access to pending utilization review (UR) and peer review-related legislation. Member organizations receive regular updates on pending bills and laws that affect the provision of IRO service, as well as other lines of business.
•Immediate access to current legislation, regulations and rules that affect all NAIRO member lines of business through legislation/regulation library available only to members.
•An easy reference UR/IRO compliance spreadsheet which summarizes all workers’ compensation UR, group health UR and IRO requirements for each state.
•A coordinated marketing program that uses press releases, white papers, and other articles through national media outlets, to promote independent review and other lines of business.
•Annual NAIRO Conference, for strategic planning and networking among members.
•In Development - URAC Site/Desktop Exit Surveys completed by each member after a URAC visit, which provides important feedback to other NAIRO members regarding URAC trends, preferences and common issues that may arise during a site visit.
•NAIRO Accreditation Committee, which monitors all accreditation modifications, issues and concerns that arise over the course of the year.
•NAIRO Blog to foster communication between NAIRO members and other stakeholders regarding important accreditation, independent review and related issues.
All the above mentioned benefits provide members with the unique opportunity to help shape health care policies and trends. If you have any questions or would like an Application Package please contact Gib Smith, Executive Director (571-436-2670) or Meredith Merlini (215-352-7800, extension 121).
Membership applications can also be downloaded off this website.
Health Plans and IROs Can Work Together to Determine Proper Care for Eating Disorders
Lansdale, Penn. — June 8, 2009 — Eating disorders are a chronic mental health problem and affect up to 10 million females and 1 million males in the United States. Through access to clinical experts and state-of-the-art medical information, independent review organizations (IROs) provide a simple and lasting solution to decrease costs for patients with anorexia, bulimia, binge eating and laxative abuse. Additionally, they deliver the appropriate standard of care, says NAIRO, a trade organization of IROs.
“The average cost of treating a patient with anorexia to health insurers exceeds $6,000 a year,” said Joyce Muller, president of NAIRO. “By identifying and providing the appropriate level of care initially, health plans can reduce the cost of managing these mental health problems.”
Treatment
In the United States, direct medical costs for treating patients with eating disorders falls on average between $5-6 billion a year. Underweight individuals with eating disorders who abuse laxatives, binge and purge face several medical risks. “Eating disorders require long-term counseling or psychotherapy linked with careful attention to medical and nutritional needs,” explains Dr. Barbara Center, Medical Director at Prest & Associates, Inc., an IRO providing psychiatry, addiction medicine and behavioral healthcare reviews. “Determining the level of care, its appropriateness and duration are best determined by an eating disorder specialist who understands the approaches various treatment centers take.”
Dangers
According to Dr. Center, eating disorders can cause severe damage to many organ systems, including serious cardiovascular symptoms. Identifying the appropriate level of care can prevent these problems that help push the cost of treatment higher. Incorrectly identifying and inappropriately denying service not only can lead to a patient’s death, but could result potentially in expensive litigation. Cutting-edge mental health experts from IROs offer a simple and effective solution for health plans to avoid such costly problems.
“IRO specialty reviews provide a mechanism to assure that enrollees are getting the appropriate level of care, when they need it and for the proper length of time,” said Muller.
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review. Its members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com
IROs Help Cut Health Plan Costs during the Recession
Evidence-based, Unbiased Determinations Use Latest Clinical Information
Lansdale, Penn. — May 12, 2009 — Health care spending today equals 17 percent of the U.S. gross domestic product (GDP). By 2017, experts project it will equal 20 percent. Most politicians and healthcare experts agree the current system is burdened by inefficiencies, inflated prices, poor management and waste that increases medical care and health insurance cost. Independent review organizations (IROs) provide a simple and immediate solution to decrease costs while delivering the right standard of care to plan enrollees says NAIRO, a trade organization of IROs.
“IROs are a smart way to help reduce costs in today’s healthcare system,” said Joyce Muller, president of NAIRO. “Using an evidence-based approach, they can help health plans determine the appropriateness of treatments, often saving them money in the short- and long-term.”
Medical Necessity Decision-making
According to Muller, IROs can provide a broader range of credentialed, licensed and actively practicing specialists focused on medical niches than health plan providers or payers can afford to employ. Access to narrowly focused specialties helps plan providers and administrators tap the specific expertise needed for the decision making process.
Using unbiased and evidence-based determinations, IROs help health plans decrease the likelihood and cost of appeals and litigation. At the same time, they ensure plan enrollees gain coverage they deserve for complex or controversial cases, such as multiple organ transplants or medically necessary surgery.
IROs can also aid health plans with reviews of medical treatments that may be unnecessary or considered experimental. Treatments falling into these categories can increase health plan costs.
Outsourcing complex cases or appeals to an accredited IROs provides health plans with evidence-based determinations from medical specialists with up to date knowledge that help ensure plans make correct coverage decisions. In addition, evidence-based decisions assist health-plan members’ understanding of the reasons for a coverage denial or approval.
“Spending money with an IRO to determine complex and controversial issues is simple way to reduce health costs during a recession,” said Muller. “Recent research has shown that for each dollar spent on an IRO, a healthcare plan can save up to $15. It’s sound business and creates member goodwill to pay claims correctly and on time, while avoiding a costly appeal or legal actions.
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review. Its members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information, visit www.nairo.org.
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com
IROs Help Determine Medical Necessity of Growth Hormone Therapy
Lansdale, Penn. — April 14, 2009 -- Today the human growth hormone (HGH) industry approaches $2 billion a year. It claims benefits for enhancing athletic performance, anti-aging and stimulating growth. Unfortunately, many of these remain unproven says NAIRO, trade association of independent review organizations (IROs) whose members see daily requests from health plans asking about the medical necessity of growth hormone therapies (www.nairo.org).
Because of its dangers, the Food and Drug Administration (FDA) tightly controls HGH and prohibits doctors from prescribing it for any use the agency has not specifically approved. For example, if doctors prescribe the drug to enhance athletic performance or reverse aging they are breaking the law.
“There’s much confusion about growth hormone therapy, even among healthcare professionals,” said Joyce Muller, NAIRO president. “Health plans wanting to determine the approved uses and standard of care for the drug should consult an IRO.”
Limited Approval for Children
The FDA has approved HGH for children to treat rare genetic conditions, such as Prader-Willi Syndrome (PWS) or Pituitary Dwarfism where it has shown therapeutic benefits. In all cases, HGH treatment requires the assistance of a pediatric endocrinologist. Although it has some rare side effects, treatment with synthetic (recombinant) HGH is generally safe. FDA approved uses include idiopathic short stature, growth-hormone deficiency, and chronic kidney disease.
Anti-aging and Performance Enhancement Unproven
In 2002, the National Institute on Aging sponsored the most comprehensive single study on the anti-aging effects of HGH. It discovered marginal benefits and significant side effects. It warned that HGH should be limited “to controlled research studies” and not widely prescribed.
Despite professional sports outlawing HGH, the belief persists that it makes athletes stronger and faster. Nevertheless, there is insufficient scientific evidence to support this.
The FDA approves HGH in adults only for relatively rare diseases—adult growth hormone deficiency and the wasting syndrome of late stage AIDS. In these treatments, after diagnosing patients with extensive blood tests doctors must monitor them closely.
Unapproved used of HGH can lead to increased health problems including diabetes, heart problems, liver problems, kidney problems, cancer, or death. Moreover, purchasing HGH online is risky because of the possible lack of quality control by manufacturers not approved by the FDA that can result in contamination by other drugs or steroids. Additionally, HGH misuse and its related side effects can increase health plan administrative and litigation costs that cause consumer premiums to rise.
“Health plans should be cautious about approving HGH therapies,” Muller said. “Because HGH carries sanctions for indications not approved by the FDA, health plans must consider the medical necessity of each case carefully to protect themselves, their providers, and their members. IROs can help them determine whether there’s a real medical need.”
For help finding an IRO to review the medical necessity of HGH therapy, health plans and payers can contact NAIRO (www.nairo.org).
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com
Source: NAIRO
IROs Help Cut Health Payers' Costs and Improve Image
Lansdale, Penn. — Feb. 24, 2009— In this recession, healthcare payers are challenged to do more with less, while delivering the same value to their members. For help reviewing complex or controversial appeal denials, they can find an independent review organization (IRO) through NAIRO (www.nairo.org), a national trade organization of IROs.
NAIRO members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. The organization works to promote the value and integrity of the independent medical review process.
“Many states and the federal government require a timely independent review of denied appeals,” said Joyce Muller, president of NAIRO (www.nairo.org). “During a recession payers are forced to cut costs, and outsourcing their medical claims and appeals decisions to IROs is even more compelling.”
Specialty-matched reviews at lower costs
The number of medical specialties is growing and it would cost a payer millions of dollars to build and maintain an in-house panel of medical specialists that could provide the same clinical expertise found in an IRO. IROs recruit, train, credential and manage hundreds of specialists and subspecialists who are up-to-date on current treatments, procedures and technologies in their fields. Because they provide the clinical depth a payer cannot afford to maintain on staff, IROs can meet most regulatory, payer and member needs by providing unbiased, evidence-based decisions at lower costs. This reduces payer administrative costs, the number of subscriber appeals and potential litigation.
According to Muller, accredited IROs, like the 16 members of NAIRO, provide matched specialist clinicians with credentials similar to the provider recommending a treatment under appeal.
Because payers cannot employ every “same-kind” specialist needed to review subscribers’ appeals as federal and state laws require, they can incorrectly approve or deny the appeal based on inadequate knowledge. This undercuts their profitability and consistency of coverage determinations.
Improving coverage policy accuracy
Although ERISA, Department of Labor and most state regulations call for independent review of appeals, many payers are handling appeals internally to save costs. But, this practice may increase their costs and raise the potential for litigation based on member-perceived conflict of interest. Evidence-based evaluations by IROs support these laws and can reduce the chance of paying questionable or unnecessary claims, while providing a more defensible, evidence-based determination that decreases re-examining cases that have been appealed.
Using an IRO, payers can avoid setting unwanted precedents for controversial coverage of complex and critical claims. An IRO review using up-to-date coverage policies allows payers to quickly and accurately approve or deny medical treatments. By supporting their coverage policies with current medical evidence and standards of care, they reduce unnecessary appeals and lawsuits.
Increasing subscriber good will
During a recession, payers should carefully consider the hidden costs incurred by reviewing appeals internally with the cost of using an IRO. Independent medical reviews by IROs ensure subscribers receive their coverage benefits without administrative delay, while providing objective support for payers.
“Research by some of our members shows a return on investment of $15 to $20 for each dollar spent on appeals reviewed by the IRO,” Muller said. “Unbiased medical reviews also improve good will between payers and subscribers, increase enrollments and reduce litigation opportunities.”
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com
IROs Help Decide Medically on Approved Uses of Off-Label Drugs for Cancer
Lansdale, Penn. — March 24, 2009 — As the Food and Drug Administration (FDA) approves new cancer fighting drugs for the market, researchers often study their use for non-approved, or off-label, treatments. When the studies show promise for combating other forms of cancer, physicians may prescribe these drugs to patients. By some estimates, nearly 20 percent of all drugs prescribed in the United States are for off-label use. Oncologists prescribe cancer drugs off-label about 60 percent of the time. “Researchers continually explore the effectiveness of off-label drugs on cancer, which changes the boundaries of the standard of care,” said Joyce Muller, president of NAIRO, a national trade organization of independent review organizations (IROs). “Because cancer drugs are often expensive, off-label use requires that health plans look closely at whether these drugs meet plan language for patient reimbursement or are investigational or experimental.”
What is Off-label Use?
The FDA approves a drug for a specific treatment and considers any other use “off label.” Because applying for FDA approval is expensive, it often doesn’t make financial sense for the drug manufacturer to pursue multiple uses. Although the use of many drugs off-label has been thoroughly researched and often considered the standard of care, this doesn’t mean the FDA approves their off-label use.
A few promising cancer drugs are approved by the FDA for multiple use, including Avastin, Revlimid, Imatinib and Erbitux. For example, the agency initially approved Avastin
for metastatic colorectal cancer. Then later it approved the drug for non-small cell lung cancer (2006) and breast cancer (2008). Used off-label, however, some doctors see Avastin as a “miracle drug” and may prescribe it for treating other cancers, including prostate, renal cell,
head and neck, pancreatic, ovarian and hepatocellular.
Determining Appropriate Off-label Use
Deciding whether an off-label drug is medically necessary for cancer, matches health plan language and is the standard of care requires an oncologist specializing in that specific treatment. “When a drug’s off-label benefits are supported by the latest peer-reviewed medical literature, it alters the standard of care,” Muller said. “Through an IRO, payers can access oncologists up-to-date on the latest off-label cancer drug studies.” How a drug was studied can be an issue, however. To determine the validity of a study, an oncologist must understand its parameters, including its clinical characteristics, current laboratory studies and monitoring studies. Because IROs provide oncologists who also work at leading research centers, they can determine which studies support off-label drug use as the accepted standard of care for plans. This helps health plans and UR professionals approve or deny patient reimbursements based on the latest medical evidence, as well as update their plan language and coverage policy. This may reduce the number of appeals for off-label drug coverage and any associated administrative costs a plan incurs. “When deciding if it’s appropriate to reimburse patients for using off-label cancer drugs, health plans should tap into the oncology expertise of an IRO,” Muller said. “Because plans
cannot afford to hire every oncology specialist needed, an IRO can provide supporting evidence that will show whether the off-label use is experimental, investigational or the standard of care.”
For help finding an IRO to review the off-label use of cancer drugs, contact NAIRO (www.nairo.org).
About NAIRO
NAIRO works to promote the value and integrity of the independent medical review process. Its members embrace an independent, evidence-based approach to medical review for resolving coverage disputes between enrollees and their health plans. For more information,
visit www.nairo.org.
IRO Decisions Balance Health Plan Payouts
Against Patients’ Need for Care
Evidence-based medical decisions push standard-of-care forward
Lansdale, Penn. — April 29, 2008 — Independent review organizations (IROs) are evolving as important intermediaries that balance payers’ and patients’ rights says NAIRO, an organization of IROs.
For the payer, IROs help health plans make better evidence-based healthcare determinations for patients while helping to manage plan costs. For plan enrollees, IROs help ensure that each member receives the coverage stipulated by a plan.
“IROs cannot monitor health plans or guarantee an enrollee treatment, but we help balance the needs of the healthcare payer with those of the plan enrollee by providing up-to-date medically-based evidence about a treatment,” says Joyce Muller, NAIRO president. “Ultimately, this is good for our healthcare system, because it means better coverage for patients and lower costs for payers.”
IROs often interpret the health plan language and consider how it compares with evidence-based medicine and the accepted standard-of-care. This practice assures that patients receive the care they need and protects payers from excessive costs.
It’s well known that many health plans exclude cosmetic surgery. However, sometimes a procedure that might be cosmetic for one person can be medically necessary for another. For example, an IRO might find that:
• Breast reduction is medically necessary for a woman with excessively large breasts that cause her back pain.
• Refractive laser eye surgery is needed by a firefighter intolerant of contact lenses when wearing glasses would pose him a job risk.
• Eyelid surgery is required if a patient has visual interference at 20 degrees above horizon and taping their eyelids back improves his vision 20 degrees above the horizon.
“When weighing the medical evidence and insurance benefit, IRO opinions often provide payers with specialized medical insights they can’t otherwise afford,” says Muller. “This assures that their enrollees receive evidence-based opinions about the medical necessity of a treatment and at the same time can save health plans money.”
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 www.nairo.org.
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com
New NAIRO Position Paper Released
Lansdale, Penn. — Sept. 15, 2008 —NAIRO, the nation’s leader in transforming healthcare, announced the release of a new position paper entitled “A Vision for Improving Health Care in America.”
The five-page paper briefly outlines four important points that can help improve the uniformity of the nation’s healthcare:
•Moving toward universal health care under a multi-payer system to increase the number of insured Americans
•Creating a national policy defining the role of independent medical review to help reduce healthcare costs and increase uniformity
•Establishing a uniform national policy clearly describing the process for consumers to appeal for coverage denied by a medical reviewer, and strengthening independent review mechanisms for appeals
•Making decisions about healthcare claims more uniform by basing them on evidence-based medicine that combines both a doctor’s clinical expertise and the best available clinical evidence available from systematic research.
“We believe these four points are key steps toward providing more uniform access to healthcare and streamlining America’s existing healthcare system,” said Joyce Muller, NAIRO president. “As the 2008 political season heats up, we hope both presidential candidates and state representatives address these points as they discuss national healthcare issues.”
NAIRO’s position paper is available on its Website, http://nairo.org/_pdf/NAIRO_PositionPaper2008.pdf, for downloading and comment.
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 www.nairo.org.
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com
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Patient Rights Extend to Independent Review
Most state legislatures—43 states and the District of Columbia—have passed some form of Patients’ Bill of Rights act. Among other things, this act gives patients’ the right for an independent review if their healthcare case is denied.
This right is important, because healthcare-plan providers often deny treatment based on issues other than the medical necessity of a treatment. Just a few of these reasons include out-of-date exclusions, ambiguous plan language and meeting financial objectives. In addition, often health-plan business goals are in conflict with their service delivery.
However, this is not a David and Goliath contest any more. According to an article in Parade magazine by Lori Andrews, a health law professor at Chicago-Kent College of Law, 50 percent of the patients’ challenging their denials get them reversed and independent medical review organizations (IROs) are helping these patients get the treatment they deserve.
Often licensed and URAC accredited IROs like those involved in NAIRO review denial claims and reverse them based on current literature. One purpose of NAIRO is to offer unbiased medical decisions about healthcare treatments for health plan providers and consumers so that the appropriate healthcare plan providers can deliver care to those who are paying for it.
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