Organizations

Every healthcare organization has different policies and procedures relating to the handling of healthcare appeals or appeals of adverse determinations. While state and federal regulations dictate in large part how these appeals are handled, each healthcare payer has much leeway in determining exactly how to deal with them. Many companies have first-level appeals or second-level appeals that are done inside their own organization and use the IRO as a third-level appeals entity. Other healthcare payers actually send all of their appeals directly out to IROs immediately as their first-level response. Some payers use the IRO’s determination as binding upon their decision making process as a matter of best practice. Other health insurance payers consider the IRO independent medical review to be another input to the decision making process but reserve the right to make a final determination in house.

So, health plans use IROs differently to satisfy regulatory requirements. IROs represent a very flexible approach capable of being used and deployed no matter what the healthcare payers’ internal process may look like. We have clients that perform some first-level appeals internally and others automatically send those same types of cases from the same health plans out to us. This level of flexibility and adaptation on the part of the independent review organization is what makes IROs so appealing to health insurance payers: They can be flexibly deployed around just about any type of process both internal and external.

External appeals and external reviews by IROs are a part of many state insurance commissioners’ appeals processes. In almost all states, state insurance commissioner organizations have set up processes whereby any patient who has been denied a benefit by their health plan and has gone through an appeal can then appeal to the state insurance commissioner. The state insurance commissioners have set up panels of independent review organizations to process those requests from patients. The IROs render independent medical review determinations and responds directly to address any concerns that patients might have directly to them.

This consumer advocacy element is an important part of the checks and balances that we have in our health care system. For example, it assures that people who are paying for insurance coverage indeed get what they’re supposed to receive while, at the same time, assuring that people who are covered under insurance but are receiving unnecessary treatments outside of the standard of care are denied those treatments. By denying treatments that are unnecessary, the healthcare system assures that more resources can be allocated towards those who deserve them. Independent review organizations serve an important part of the external appeals process with health insurance payers.