Independent Review Organizations (IROs) in Healthcare: An Important Part of Progress

The healthcare industry continues to be one of the fastest growing industries in the United States and is the largest source of jobs in the country. That’s not surprising as U.S. healthcare spending is approximately $3.3 trillion or $10,348 per person annually. According to the Peterson-Kaiser Health System Tracker, relative to the size of its wealth, the U.S. spends a disproportionate amount on healthcare compared to similar high income countries.

One service within the healthcare industry that has experienced notable growth is independent medical peer review, conducted by independent review organizations (IROs). A big contributor to this growth is the Affordable Care Act as it allows for the use of external IROs to serve as unbiased, third-party reviewers of denied medical claims to determine whether or not a healthcare service is appropriate and medically necessary.

IROs play an important role in the goal of making healthcare safer and more affordable for every U.S. resident. They also offer advantages for health plans and their patients, including reduced costs, access to clinically trained resources, improved compliance and objective decision-making. In this blog, we’ll examine each of these benefits in more detail.

Controlled Costs

Though it may seem more expensive to outsource work instead of performing it in-house, employing the services of an IRO enables an organization to pay on a case-by-case basis, thereby reducing ongoing expenditures. By using an IRO with experienced team members who have in-depth industry knowledge, healthcare organizations can eliminate the need for ongoing review training for their employees.

Reliable Resources

The best IROs invest in secure technology to assist their clients and are able to provide access to specialists, subspecialists and board-certified physicians in all 50 states. Their experience in dealing with complex cases makes them a reliable resource and allows in-house staff to focus on other tasks. Plus, they can work with clients to streamline the review process based on their extensive knowledge of the healthcare industry.

Compliance Assistance

HIPAA, Medicare and the HITECH Act are only a few of the legislative and regulatory statutes that govern the healthcare industry. IROs have to adhere to state and federal guidelines and keep up-to-date on any changes. Therefore, organizations utilizing the services of an IRO are guaranteed a dependable legislative resource for their reviews.

Necessary Objectivity

IROs are a popular choice for medical reviews because they offer unbiased decisions and eliminate conflicts of interest. They ensure that each party is considered through a resolution that examines clinical documentation, applies evidence-based guidelines and plan language, and oftentimes includes peer-to-peer calls in which the treating physician and reviewing physician confer over a case.

Advanced Medical Reviews (AMR) offers its healthcare clients a reputable and cost-effective method for meeting their independent medical review and utilization management needs. Our team is comprised of highly-trained compliance staff and specialized case review physicians whose work is guided by our company’s belief that every patient should receive quality healthcare.

Our portals and platform are HITRUST CSF-certified and we are fully accredited by URAC as an Independent Review Organization (internal and external reviews) and in Health Utilization Management. Our clients include health plans, managed care groups, workers'​ compensation and disability clients, TPA, IPA, Medical Groups, MSO, PPO, HMO, Medicaid and Medicare teams, hospitals and government entities. To learn more about AMR and the markets we serve, check out our breakdown of AMR's Services.