Regardless of the outcome of pending healthcare legislation, a need still exists for independent review organizations to ensure covered treatments are medically necessary and appropriate.
Westerville, Ohio (PRWEB) 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 sp 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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