Increasingly, healthcare providers, insurers, medical directors and case managers are turning to Independent Review Organizations (IROs) to collaborate on the decision-making process for medical claims. At question, however, is when in the decision-making process does this make the most sense? Here are the top 10 signs to identify when to bring in an IRO:

1. Your case is in a highly specialized area. Case managers often need access to a breadth and depth of medical expertise beyond what is available among their staff or extended network. Information and scientific advances in the medical field are increasing at unprecedented rates. Medical disciplines fragment into new specialties every year. There is simply too much medical information today for one doctor or case manager to keep up on. This means medical directors and claims managers need access to outside medical knowledge beyond their expertise. An IRO can provide such access to highly specialized doctors whose unbiased expertise is otherwise unavailable even to large healthcare companies or third-party administrators handling claims management. Because of the depth of expertise in its specialist network, and the volume and breadth of claims it reviews daily, an IRO provides a mechanism for quickly and consistently applying expert knowledge to medical claims decisions.

2. Your case has a high risk of appeal. With claims that have potential high appeal rates or other risks, health plan providers and insurers may want an external, independent and objective perspective about the claim. Using an IRO to decide cases based on medical need avoids the appearance that the case review might be tainted by potential biases of a doctor on their payroll, or even the financial goals of the insurer or administrating group.

3. Your case may be litigated. When its necessary to have a definitive decision based on medical fact, organizations must ensure that a case is reviewed properly. Using an IRO helps guarantee that questionable cases or appeals receive unbiased reviews as mandated by state and federal regulations and that patients receive the medical care directed by their healthcare insurance. In cases of litigation, an IRO documents how it decides every case providing an audit trail.

4. Your cost of a claim or treatment is high. Health insurers are under constant pressure to reduce costs. Outsourcing medical claims decision-making to an IRO allows providers to reduce expensive doctor overhead by paying only for what they need, when they need it.

5. Your case seems suspect. When dealing with suspected fraudulent cases, turning to an IRO to review the case can provide an objective, disinterested third-party response that exposes the deception. IROs can review a patients case to discover if treating doctors have followed all the necessary processes leading up to a proposed procedure and met accepted medical practices. They can also determine whether the patient needs the medical procedure recommended.

6. Your organization is subject to state or federal deadlines. When payers must meet mandated state and federal deadlines, they can use an IRO to hasten the review of a case to ensure that deadlines are met every time.

7. Your claims and reviews are piling up on your desk. Bringing in an IRO early in the case review process helps streamline case flow and increase case review productivity to ensure patients get the care they are entitled to as fast as possible.

8. You need an impartial review. Healthcare organizations may need a buffer for their clinicians from any real or perceived conflict of interest. IROs have no relationship with the organization, the doctor, or the patient, and provide objective decisions based solely on the latest medical facts.

9. You believe the treatment is experimental. Medical directors and case managers need to ensure that a denial or an approval is based on the accepted science of medicine. An IRO can often provide a review doctor with the same credentials as the one who made the original recommendation and who stays current with the latest medical necessity practices.

10. You have a shortage of specialists on staff. Claims decisions are made by doctors. An IRO can help your company expand its medical staff expertise without incurring the expense of full-time professional salaries. An IRO can serve as an extension of your medical office to provide expert knowledge to claims decisions because it has access to medical specialists within its network of doctors.

There is increasing pressure on payers and plan administrators to not only make the right decision for the patient but also reduce healthcare insurance costs, premiums and co-payments. To make this happen, many health insurers and third-party administrators are turning to IROs for deeper medical expertise, and approval or denial of a claim based on medical fact, not anecdotal evidence. Using an IRO is an efficient and defensible way to manage a health plan properly for both the insurer and the patient. As unbiased advocates for managing healthcare costs, IROs ensure that every claimant is properly served, every time.