Efficiently Utilizing Your Independent Review Organization
Efficiently Utilizing Your Independent Review Organization
It is similar to working with a doctor while dealing with an Independent Review Organization (IRO). How can you be sure that you will receive the necessary treatment to alleviate your illness? My insurance will pay for this procedure, right? When will I be able to begin treatment? Has the doctor gotten all the information they need to make an informed decision about my care?
Take into account the particular problem(s) you are attempting to address when you ask for an independent medical review. By making sure your IRO is looking at the right documents and facts and making the right choices on the issues at hand the first time, you may keep costs to a minimum by knowing what questions to ask first.
The question of whether a patient meets the criteria for a procedure according to your plan language and the question of whether the procedure is medically necessary are often confused. Consider the following scenario: Mary Smith's primary care physician has recommended a chiropractor to alleviate her back discomfort; however, her insurance policy expressly states that chiropractic care will not be covered under any circumstances. The treatment should be denied regardless of whether it is medically necessary or if the doctor has recommended it. Identifying the problem you are attempting to solve is an important first step in communicating with the IRO reviewer.
There is an additional issue with experimental and investigational treatments. It can be challenging to stay up with the medical community's approval of a treatment as a scientifically acknowledged technique and the ongoing status of experimental procedures due to the ever-changing nature of technology, medications, and treatment protocols. In order to save time during the review process, it is important to know that the plan exclusions always take precedence over the inclusions. Crucial to the choice is the plan language's description of experimental/investigative.
In order to facilitate your collaboration with your IRO and guarantee consistent, meaningful results for patients and your company, we have compiled the following list of suggestions:
Before formulating your questions—which may concern issues like plan language interpretation, experimental/investigative procedures, medical necessity, or standard of care—be sure to identify the precise problem you are attempting to solve.
Put together a list of questions that need to be answered with a clear and supported rationale.
If you want an official answer, you need to supply all the necessary plan language and chart documentation.
After all other avenues have been explored, a simple "no" from your IRO can be the final push you need to convince the record holder to hand over all the necessary documents for your review.
Please be informed that it is the obligation of your IRO to contact you prior to the commencement of any independent medical review in order to address any inquiries or clarifications. Verify that the optimal time to reach that individual and who to contact are both known to your IRO.
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