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WHAT IS INDEPENDENT MEDICAL REVIEW?

Peer review, independent medical review, hospital peer review, and medical peer review, have all become interchangeable terms in the healthcare industry. As is often the case, different organizations and individuals use their own vocabulary when talking about the same thing. In general, the term “Peer Review” has become a simplified substitute for all these phrases.

Whatever term is applied, the core function is to obtain the objective determinations of physicians who are not a party to a particular treatment. They can approve or deny medical claims based on medical evidence, and accepted standards of care. These physicians must be board-certified and in active practice.

Independent review typically (but not always) occurs after all appeals mechanisms available within a health benefits plan have been exhausted. Independent review can be voluntary or mandated by law.

ORGANIZING THE INDUSTRY

While URAC has developed evidence-based measures and accreditation programs for independent medical review since 1990, their charter as a standards body precludes ties to any industry-interest group.

In 2001, Dr. Winifred Hayes led efforts to form the National Association of Independent Review Organizations, or NAIRO. The primary objectives of NAIRO are:

  • developing guidelines for solving common industry problems,
  • promoting standards for these reviews,
  • educating consumers about their rights for claims appeal,
  • helping define the role of IROs in the evolving healthcare landscape.

Since its formation, NAIRO has assisted policy makers at both the federal and state level with position papers and analysis of issues. NAIRO has also helped its member organizations demonstrate the value of URAC accreditation and their processes for independent medical review.

NAIRO LEADERSHIP

NAIRO is a member-driven, non-profit association. NAIRO Officers are elected to a two-year term by ballot of member organizations with voting rights. These Officers, along with the Executive Director and the previous NAIRO President, form the NAIRO Executive Committee.

NAIRO’s 2023-24 Executive Officers include:

President: Valerie Aiello, RN, MSHI

Valerie Aiello is Vice President of Healthcare at Healthcare Quality Strategies, Inc. (HQSI) located in East Brunswick, New Jersey.  She has over 20 years of experience managing medical review and quality assurance for federal, state and commercial contracts.  She plays an integral role in the leadership of a national panel of physician and nurse reviewers at HQSI, as well as the strategic development team.

Vice President: Eric Hatfield, Esq.

Eric Hatfield is counsel for Dane Street, LLC, a medical review company. He serves as Dane Street’s Director of Legal, Compliance, and Regulatory Affairs. He is in charge of compliance, accreditation, and privacy matters, contract development, legal research, and the general legal affairs of the company. Mr. Hatfield joined Dane Street in 2021, shortly after graduating from Southern University Law Center in Baton Rouge, LA. Also in 2021, soon after joining Dane Street, Mr. Hatfield was admitted to the Louisiana State Bar. He has been in his current role with the company since his admission to the bar. 

Past President: Frances Scott

Frances Scott is the Director of Operations for the Empire State Medical, Scientific and Educational Foundation (Foundation), an independent review organization and coding validation company.  Ms. Scott is responsible for the administration and management of all review programs and activities in the Foundation’s Upstate NY office.  She works with the management team in the development and implementation of ongoing organizational strategies, policies and procedures.  Ms. Scott also is involved in contract negotiations with hospitals and payors seeking medical review services from the Foundation.  She currently serves as Finance Director for the New York Health Information Management Association (NYHIMA), where she has also served as President and Education Director.

Secretary: Charlene Beyah, R.N., BSN, J.D.

Charlene Beyah, R.N., BSN, J.D., serves as the Corporate Compliance Officer for iMPROve Health, formerly known as MPRO, Michigan’s designated Quality Improvement Organization (QIO). iMPROve Health, a 501 (c)(3) non-profit corporation, is a recognized leader in healthcare quality improvement, with wide-ranging experience in independent medical review, utilization review, Medicare and Medicaid programs, research methodologies, data analysis, and outreach strategies. As chair of iMPROve Health’s Compliance Committee, she is responsible for monitoring adherence to iMPROve Health’s Compliance and Ethics Plan. Ms. Beyah also brings more than 20 years of long-term care nursing experience in her additional role as an Informal Dispute Resolution (IDR) reviewer.

Treasurer: Sarah O'Hara, CCEP

Sarah O’Hara is the Vice President of Compliance, Regulatory Affairs and Quality Assurance for National Medical Reviews, Inc., an independent review organization and certified independent dispute resolution entity.  In her role at National Medical Reviews, Inc. she oversees the compliance and quality management programs, policies and practices.  She has over twenty years in the healthcare industry with particular focus on providing expertise and guidance in interpreting policies, regulatory and/or governmental regulations and commercial guidelines.

Member at Large: Ed Bolton

Mr. Bolton is the Founder and CEO of Nexus Medical, a national clinical review organization that has received multiple accreditations while dedicating the highest quality of service to clients across the nation. Mr. Bolton’s commitment and medical experience span more than 25 years, with an emphasis on business center influence, group health, workers’ compensation, auto liability, and disability. Mr. Bolton is an active board member in several civic, non-profit and for-profit organizations. In addition to serving as NAIRO’s President he is a member of the Workers’ Compensation Research Institute (WCRI) Texas Advisory Board and the Dean’s Advisory Board for Wayland Baptist University and McCoy College of Business Administration, Texas State University. Mr. Bolton’s professional accomplishments include the completion of a Master’s Degree from the University of Nebraska with residency training in Occupational Medicine as well as authoring a number of articles related to disease management, workers’ compensation injury, the Patient Protection and Affordable Care Act, and medical briefs on conditions such as lower back pain.

Executive Director: Gib Smith, Esq.

Mr. Smith is an independent management consultant, based in Purcellville, VA. He has been Executive Director of NAIRO since October 2008. Prior to NAIRO, he served in positions with MAXIMUS and MCMC, backing his three decades of experience in the IRO industry.