Medical Review Solutions: Specialized Services for the Healthcare Industry

Do you know what all of the following types of healthcare organizations have in common? Hospitals, managed care organizations (MCOs), third party administrators (TPAs), disability insurance carriers, workers’ compensation carriers, reinsurers or stop-loss carriers, utilization review and medical management firms, large self-insured corporations that pay and oversee their own healthcare benefits, property and casualty firms that are paying out medical claims, fraud units working inside larger health plans and special investigative units.

Obviously, they’re all players in the healthcare industry in the United States. But another similarity is that they all utilize the services of an independent review organization (IRO).

What is an IRO? It’s defined by the National Association of Independent Review Organizations (NAIRO) as a third-party medical review resource which provides objective, unbiased determinations that support effective decision-making based only on medical evidence.  

IROs offer a cost and time-effective resource to handle medical reviews when one of the previously mentioned organizations needs the services of a specialty physician or has an overflow of cases. They provide independent, unbiased medical expertise using evidence-based recommendations and are up-to-date on federal and state compliance guidelines.

Many IROs provide services that specialize in a specific area of medical review. At Advanced Medical Reviews (AMR), three of the primary types of case reviews we handle for clients are group health, pharmacy benefit manager (PBM) and workers’ compensation.

Group Health

About half of U.S. employees have employer-sponsored group health insurance. Group health policies are designed to provide coverage to a group of members, enabling them to purchase insurance at a reduced price. Employers benefit from providing group health insurance to their workers because the insurer’s risk is spread across a group of policyholders.

IROs assist group health insurers by providing specialized medical review, sometimes in the form of a utilization review. The type of review aids payers in improving coordination of care, verifying members receive high-quality, medically necessary care and improving organizational oversight.

IROs also are often requested by payers to conduct physician-level review of medical records or drug utilization reviews. Both of these services are used to assess or verify the medical necessity of a patient’s medical treatment and help reduce unnecessary healthcare spending.

AMR provides a broad range of services to both commercial and government-sponsored group health organizations. Our physician and allied health reviewers assist in decision-making for utilization management and appeals departments, provider quality, SIU, financial integrity and more.

Pharmacy Benefit Management

The goal of pharmacy benefit managers (PBMs) is to manage prescription drug costs by negotiating with pharmaceutical companies. Overall, PBMs save the healthcare system an average of $6 for every $1 spent on PBM services. As we mentioned in a previous blog, they reduce drug costs by:

• Offering Amazon-style home delivery of medications and creating select networks of more affordable pharmacies
• Encouraging the use of generics and more affordable brand medications
• Negotiating rebates from drug manufacturers and discounts from drugstores
• Managing high-cost specialty medications
• Reducing waste and improving adherence

IROs assist payers by helping them in the external review process to determine exceptions for specialty drugs for members. They also ensure treatments align with recent evidentiary guidelines for efficacy, safety and value. At AMR, we partner with payers to help them incorporate medical-based guidelines into their formularies and make sure their members’ medication regimens are based on medical criteria, guidelines and research.

Workers’ Compensation

More than 129 million employees in the United States are covered by workers’ compensation, which provides cash and medical benefits to workers who are injured or become ill in the course of their employment regardless of fault. Some IROs review workers’ compensation and disability claims and appeals as an unbiased third party.

In a workers’ compensation claim review, the complete medical care of the injured employee is reviewed, including treatment, medication, procedures and rehabilitation by the original medical provider. The reviewer then makes a recommendation based on the findings to accept or overturn the denial. At AMR, Official Disability (ODG), American College of Occupational and Environmental Medicine (ACOEM) and state-specific guidelines are utilized by our physician reviewers who understand the nuances of workers’ compensation.

If you’re interested in becoming a physician reviewer for AMR, please register, and one of our representatives will review your information and follow-up as soon as possible.