Safeguards protect against conflict of interest in the external review sphere

June 9, 2017

Conflict of interest is serious business in any industry, and it is of paramount importance for the medical review process within health care – where people’s health and well-being are at stake.

Recently, the National Association of Independent Review Organizations (NAIRO) released a white paper discussing the vital function of independent medical review, including an in-depth discussion of the conflict-of-interest concerns facing the external review industry.

For those not familiar with this important part of health care, independent review organizations (IROs) serve as objective arbiters of insurance-related coverage decisions, determining if certain health services, which may be in dispute, are covered under a patient’s health plan.

In a typical appeal case, a patient can exhaust up to two levels of internal appeal, which are performed under the health insurer’s appeals process, before the appeal moves to a third review or external review, or outside of the health insurer’s purview – and that’s where an IRO comes in. As an impartial body, an IRO conducts an independent review of such appeal cases. Sometimes, an IRO performs the initial or internal levels of appeal, as well.

IROs are entrusted to be the impartial balance between the patients, providers, and payers.

Paramount to the healthy functioning of the review process is ensuring the independence of the process by eliminating even the appearance of any conflict of interest. At a fundamental level, an IRO operates in an environment in which, by definition and with safeguards in place, the organization, staff and reviewers are free of any financial, organizational or other conflicts that may jeopardize the conflict-free nature of its review process.

Let’s take a look at some of the checks in place that are designed to mitigate or eliminate any conflicts.

Industry standards, regulations help avoid conflicts

For an IRO to legally operate, it must adhere to a number of industry standards, including state laws and guidelines adopted under the Affordable Care Act (Section 2719). Further, all NAIRO members, which are URAC-accredited IROs, must meet stringent standards in order to maintain their accredited status.

“URAC accreditation standards mandate certain requirements for review organizations that provide both internal and external review services,” notes Gib Smith, NAIRO Executive Director.

“For example, to be in compliance with URAC’s conflict-of-interest standards, if required by the state they are doing business in IROs must disclose the names of the organizations for which it provides internal review,” adds Smith.

Accredited IROs must also stand by the stipulations set forth in the NAIC Uniform Health Carrier External Review Model Act (Model Act), which provides a framework for objective review determinations. For instance, as noted in the recent white paper, the Model Act states that IROs must act as separate business entities from health plans.

Additional regulatory language adds another layer to the pursuit of an objective process. Conflict-of-interest standards also apply to individual clinical reviewers who are contracted by IROs and who perform internal, external or utilization reviews.

Again, both the Model Act and URAC accreditation standards apply rigorous checks on reviewer conflict of interest. Among other requirements, the URAC standards stipulate that the reviewer “was not involved in the specific case in question,” “has no professional, familial or financial ties” with the involved parties and, of course, “does not receive compensation for the review decision dependent on the outcome of the case,” describes Richard Lynch, Chair of NAIRO’s Membership and Marketing Committee.

Additionally, “each assigned reviewer undergoes a rigorous internal conflict-of-interest check before accepting a case and must sign an attestation certifying the same as part of their advisory opinion,” says Smith.

For more on conflict of interest with independent medical review, check out NAIRO’s recent white paper and also a position paper that the organization released in 2015.

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