Step-by-step Guide to the Independent Medical Review Process

Most businesses have established processes and procedures to ensure employees follow the correct sequence of steps that results in high-quality products or services. Providers of independent medical reviews (IMRs) are no different.

One of the most common types of IMR providers are independent review organizations, or IROs. These entities perform IMRs to establish the medical necessity or experimental and/or investigational status of treatments, and to evaluate other issues impacting appropriateness of medical care.

Usually requested by private and government-sponsored health insurance organizations, the purpose of IMRs is to verify that medical decisions are based on and adhere to evidence-based medical standards, current and relevant clinical research, regulatory requirements and practice guidelines.

Some of the proven benefits of IMR include:

• Patient protection
• Positive impact on health plan review processes and other health care management activities
• Reduction of not medically necessary services and procedures
• Decreased waste of health care resources
• Improved patient satisfaction through provision of an unbiased, evidenced-based external determination.

Step 1: Request of IMR

Most often, IMRs are initiated by insurance companies and other payers when they disagree with the appropriateness of a health care provider’s course of treatment for a specific patient. However, health plan enrollees also have the right to request an IMR to be conducted when coverage for medical treatments or services is delayed or denied by their payer. In addition, a health care provider can also initiate an IMR request, especially when emergency treatment is involved. Once initiated, IMR requests are then performed via internal processes (e.g., by following an insurer’s own IMR process) or by sending the request to an IRO.

Step 2: Assignment of reviewer

Once an IRO receives an IMR request, it is assigned to a licensed and credentialed clinical reviewer who works in the same field, and who has the same or similar specialty or subspecialty as the clinician who provided the treatment outlined in the original medical claim. The physician reviewer’s experience in dealing with complex cases makes them a reliable resource because they’re able to offer recommendations on the process based on their extensive knowledge of the health care industry and the treatments or procedures being evaluated.

At Advanced Medical Reviews (AMR), our nationwide network of board-certified physician reviewers undergo a thorough vetting and credentialing process. They must sign a conflict of interest statement, confidentiality agreement and credentialing or re-credentialing forms with an attestation clause. In addition to having at least six years of experience providing care, these clinicians must undergo background checks, complete URAC training, and take part in a thorough orientation period to evaluate performance via regular audits and medical director oversight.

Step 3: Physician review of case

In IMRs, information like medical records undergo evidence-based clinical review to ensure treatment recommendations meet established medical necessity and appropriateness of care standards. This step is used to confirm that decisions about medical care are based solely on medical evidence and provide transparency for both patients and payers. Physician reviewers must adhere to strict compliance requirements for each case they review.

Step 4: Reviewer-provider discussion

This is also known in the industry as peer-to-peer discussion. Although this step does not occur on every IMR, it involves the clinical reviewer discussing the review at hand with the health care provider to gather additional information on the patient’s medical history, previous treatment, and other pertinent information not captured on the documentation reviewed. This step aims to allow the reviewer and provider to align on the best course of care for the patient.

Step 5: Final recommendation

Once the physician reviewer has completed his or her research on the case by using evidence-based guidelines and following applicable compliance requirements, they complete a written report. This report details the reviewer’s recommendations on whether the treatment or service under review was appropriate and medically necessary. This report often includes additional recommendations and lists any recommended alternative medical treatments that may be more appropriate.

Step 6: Quality assurance process

At AMR, our quality assurance team reviews all reports to confirm client requirements for formatting and quality of content are met, but more importantly, to ensure the recommendations are clinically sound. Furthermore, our reviewers’ work is routinely audited to ensure inter-rater reliability standards and that the overall consistency of reviews is of the highest quality possible.

Step 7: Written notice of final decision

Once a physician completes the review of a case, and all quality assurance processes have been followed, the IRO gives written notice of the final recommendation to the patient, the payer or the provider.

Are you interested in joining our network of physician reviewers? Contact us today for more information.