Medwork IRO: FAQ
Medwork IRO
What is an IRO?

An Independent Review Organization (IRO) provides independent medical reviews to help insurance payers make consistent, evidence-based healthcare decisions in regards to benefits coverage. An IRO is a healthcare advocate for both the patient and the payer by ensuring coverage for medically necessary treatments and eliminating overutilization. By acting as a independent and neutral party, an IRO administers timely, expert medical determinations that evaluate both the medical and insurance sides of healthcare information by granting access to objective medical expertise not readily available to payers.

Has an IRO been called other names?

Yes, IRO has been described by names such as Medical Necessity Review Organization (MNRO), External Review Organization (ERO), Peer Review Organization (PRO), Medical Review Company, as well as others. At this time, the industry has established IRO as the commonly-used name.

What purpose does the IRO serve?

When the healthcare insurer denies a benefits claim, an IRO provides the patient with a system to get the care they need and the case paid for. IROs provide unbiased, neutral decisions about medical care founded solely on the evidence and the medical necessity of a procedure. IROs also serve as a Risk Management tool and Quality Assurance Measure.

Why did IROs get started?

Approximately a decade ago, nationwide state government officials noticed that some healthcare organizations were more motivated by financial incentives than providing quality healthcare. Many individuals in the decision-making role interfered with the delivery of medical coverage in the pharmaceutical industry, physician care, medical insurers, and other key interest groups

Several states recognized that the consumers were being subjected to medical judgments by their doctor, their health plan, and a utilization reviewer. As a result, the states legislated external accountability for healthcare plans and healthcare professionals. Laws were passed to execute an independent review process that allowed patients to appeal the healthcare plan decision and obtain insight into the doctor’s conclusion.

At this time, many states have created similar laws, although it varies from state to state.  Patients denied access to healthcare must first appeal the decision to their health insurance provider.  If the decision comes back negative, consumers have the right to request a review of their case by an IRO to make a medical necessity and coverage determination.

Why would a health insurance payer need to use an IRO?

A health insurance payer would use an IRO to comply with the state insurance regulations, mandated deadlines, the U.S. Department of Labor regulations, and the federal Employee Retirement Income Security Act (ERISA). In order to manage the extensive infrastructure that is needed in-house and to efficiently handle the medical reviews, many payers outsource their medical reviews to an IRO. Also, because many payers are for-profit organizations and don’t want to be perceived as denying treatment to cut costs, many payers turn to an IRO to review special cases to provide them with the information needed to make better decisions.

What are the costs of using Medwork for independent reviews?

The cost of the review will vary based on the number of pages of medical records, the number of questions to be answered, the complexity of the case, and the turnaround time for the review. Using Medwork is an economical way for health insurers to verify that their enrollees are receiving the care they pay for. The fee is arranged when the contract is created with Medwork Independent Review.

Does Medwork Independent Review handle cases that are being appealed or reconsidered?

Yes, Medwork offers the review of patient appeals to healthcare payers nationwide. Many health insurance payers and plans that adopt best practices will automatically send all appeals to an IRO. This practice demonstrates to the member that each claim is being reviewed with the highest degree of objectivity. Health plans that continue to process appeals internally run the higher risk of lawsuits and risk the perception of conflict of interest.

What is an evidence-based review?

An evidence-based review means that the treatment recommended must have objective tests on its efficacy published in scientific/medical literature or journals.

Is an IRO able to decide if a medical treatment is experimental or investigational?

Yes, an IRO can decide if a medical treatment is experimental or investigational. The physician specialists that work with the IRO track the latest medical research literature and are aware when treatments move from the experimental or investigational stage to the accepted standard of care.

What is the Pro Term Medical Director service?

The Pro Term Medical Director service is a customized program that provides temporary or regular medical director support to insurance companies, payers, and medical management firms. This option may be considered as a viable option when the organization is unable to afford a full time medical director or doesn’t know where to find the individual with the right experience.

When does a medical-necessity review need to be done?

A medical-necessity review needs to be done whenever doubt exists as to whether or not a certain type of procedure is necessary, or whether the procedure meets the accepted standards of care. Additionally, if the treatment is experimental, investigational, or controversial, an independent review should be conducted. According to national statistics, approximately 30 percent of all medical treatments are unnecessary. This affects costs and the quality of healthcare; therefore, it’s in everyone’s best interest to reduce and eliminate overutilization.

What is external peer review and why is it so important?

External peer review has become a risk management tool and quality improvement measure that allows cases to be reviewed by a neutral, independent physician in the same specialty at an equal organization that is used to determine if a doctor’s work meets the standard of care. An external peer review is necessary when circumstances require an informed, unbiased and objective review that cannot be done internally. This includes situations where medical staff lack the specialized knowledge required to evaluate a practitioner’s performance, when other staff feel uncomfortable judging the care that was given, when personality conflicts can arise, or when conflict of interest may exist.

Why can’t a hospital use its staff physicians to conduct internal peer reviews?

There are several reasons why a hospital should not conduct internal peer reviews. The facility may not have the specialist expertise that is needed. Tightly-knit social and professional relationships lead to conflict of interest and reluctance to pass judgment on colleagues and associates. Also, there may be a personality conflict between the physician under review and the fellow reviewing physician. Finally, hospital peer review is not the highest priority in the demanding, busy schedule of medical staff. This often leads to the review not being completed in a timely manner.

When should I consider using Medwork’s external peer review?

You may consider external review to help fulfill the Joint Commission’s (JCAHO) requirement for focused and ongoing physician evaluations. Consider peer review whenever you have a sentinel event, need to credential or re-credential a physician, hire a new physician, and review a random selection of cases. External peer review is a vital risk management tool.

What specific situations prompt hospitals to arrange for an external peer review?

Situations that will prompt a hospital to seek an external peer review include sentinel events and examples include: unexpected patient death, complications, wrong site or wrong patient procedure, a delay in diagnosis or treatment, a case that involves a serious patient complaint, a case that involves disruptive practitioner behavior, an inadequate hand off between practitioners, wrong or missed diagnosis, and inpatient suicide. In addition, peer review may also be completed for randomly selected cases as a quality assurance measure in order to be proactive with routine performance data gathering and review.

Other conditions that may prompt an external peer review include a conflict of interest that compromises objectivity, situations where the issue under consideration divides the medical staff, when there is a lack of internal expertise to review the care in a certain specialty, if there is a general or specific concern about clinical outcomes, the staff is unavailable to perform the peer review in a timely manner, if there are unclear or inconsistent standards, any ambiguity in existing care analyses, or fair hearing expertise is needed or anticipated.

Does Medwork conduct on-site peer reviews?

Medwork does not conduct on-site peer reviews. The peer reviews are completed efficiently without physical contact to avoid conflict of interest, hospital politics and personality conflicts. This is done to provide an unbiased, objective review.

What types of organizations will use an IROs for reviews?

Many types of healthcare organizations will use an IRO for reviews, including managed care organizations, hospitals, medical groups, HMOs, health insurance companies, medical management firms, self-insured organizations, reinsurers, state and federal insurance agencies, etc. IROs have become an essential part of the healthcare benefits determination process.

How does Medwork Independent Review protect confidentiality?

Medwork Independent Review handles the protected health information according to the Health Insurance Portability and Accountability Act (HIPAA) standards and meets all requirements by federal law. Medwork ensures the privacy of all medical records, health benefits information and plan documents provided for external review by maintaining strict confidentiality.

What specialties does the Medwork Independent Review physician panel cover?

Medwork covers all major and minor specialties from anesthesiology to urology. In addition, Medwork has experts in alternative therapies like chiropractic and acupuncture.

What if Medwork doesn’t have specialist that we need on their panel?

Medwork Independent Review can cover any medical specialty that is called for. If Medwork doesn’t have the physician specialty on the panel that is required, Medwork can quickly recruit and qualify the specialty physician needed.

How many states have external review policies?

Currently, 44 states and the District of Columbia have legislated external review procedures through which individuals can file for an appeal through the state insurance commissioner’s office. Typically, this is the last resort for an individual that has been denied benefit coverage. It has become a common practice for leading insurance payers to adopt the use of an IRO for their own internal review and appeals process. This raises the level of impartiality and affords its members an increased confidence in the integrity of their health plan’s coverage decision.

Do IROs simply add to the growing cost of the healthcare system?

The minimal cost of using an IRO reduces the overall cost of healthcare because the IRO looks at each case objectively, based on current medical evidence, and may suggest alternative (many times less expensive) treatments and eliminate unnecessary or fraudulent procedures. Recent research has shown that for every dollar spent on an IRO, a healthcare plan can save up to $15.

How do IROs improve the healthcare system?

By protecting the integrity of the healthcare system, IROs help ensure that members of health insurance plans receive the benefits of coverage they deserve concurring with the latest standards of care. This helps to reduce the overall cost of healthcare by reducing the number of unnecessary treatments (otherwise known as over utilization). Medwork is passionate about improving healthcare quality, patient safety, reducing costs, and believes it is making a substantial difference.

What is the turnaround time for Medwork reviews?

Medwork tailors the turnaround time for each contract while meeting or exceeding industry standards. Standard, expedited and emergency reviews are offered by Medwork.
  • Standard Turnaround Time is 5 to 20 business days
  • Expedited Turnaround Time is within 72 hours
  • Emergency reviews are available