By Jim Bobeck
Most beneficiaries come in contact with an IRO (Independent Review Organization) through their health insurance plan or TPA (third party administrator). A beneficiary is refused treatment, and they get a glimpse of the appeals process in place to re-review a claim. For a more detailed understanding of the process, please visit NAIRO, a great resource for the healthcare IRO process.
IROS usually can be lumped into one of three categories: Medical necessity decisions, experimental/investigational services, and administrative/benefit denials. In the past, the first two categories have received the most attention, which requires a specialty-on-specialty physician match to review the appeal. The physician determines whether a health plan was correct in denying medical service or an experimental procedure, and the reviewer uses medical judgment and criteria to determine whether the medical facts support the service in question.
However, it’s the third category that has grown in volume, particularly due to changes under the Affordable Care Act and with more restrictive means utilized by some health plans regarding covered services and benefits. The administrative category has an amorphous quality in that it encompasses many types of issues, including covered services, out of network providers, rescissions of coverage, formulary alternative procedures, and in some cases, misutilization of services. Administrative reviews are a real catch all for beneficiary appeals.
As a result, FHAS provides attorneys and legal specialists to review such claims. Many IROs still use physicians to review such administrative cases, which is costly and fails to directly address the legal issue contained within the appeal. IROs tout the physician panel, although it’s not responsive to the current needs and trends. If an administrative/benefit coverage case is decided on medical necessity grounds, the error is only compounded as it will most certainly trigger another appeal to a higher level, or potentially, civil litigation.
Healthcare attorneys performing legal IRO reviews provides a cost-effective, higher quality, and more direct response to such cases. It can minimize potential future appeals and litigation, and it provides beneficiaries with a true “de novo” (a new, clean review). When health plans and TPAs select an IRO, their questionnaire should ask “Who do you use for administrative/benefit determinations?” at the top of the list. Beneficiaries and appellants are already asking for it, and their health plans need to respond appropriately.