Providing Transparency in External Review

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Transparency in healthcare is an important part of the Affordable Care Act (ACA). And even though ACA will either be dismantled entirely or undergo significant changes with the new administration, it’s likely that transparency will remain a key issue. Additional legislation, including the Mental Health Parity and Addiction Equity Act (MHPAEA) also provide important transparency requirements that aim at protecting individuals whose health care claims were denied. Denied claims may invite closer inspection, for instance.

Dynamic scrutiny of decisions contributes positively to the entire external review industry as long as the surrounding public policy debate is fair and factors in all perspectives. One way for payers to comply with transparency mandates is to utilize the services of external, or independent review organization (IRO). IROs, like payers, must provide transparency and take a proactive approach to pressure points such as:

  • How does the IRO function?
  • Are decisions evidence-based?
  • Does the IRO promote objective peer reviews of medical necessity determinations?

Accredited IROs are able to answer the above questions easily and with confidence. The National Association of Independent Review Organizations (NAIRO) lists organizations that have been accredited by URAC, an independent, non-profit accreditation body. URAC’s standards are uncompromising and educational, and require that independent reviewers “must complete a rigorous internal conflict-of-interest check,”[1] before they are allowed to accept cases.

In its white paper, “Understanding the Vital Role of Independent Medical Review and Utilization Review Services,” NAIRO explains that avoiding conflict of interest is of utmost importance for IROs. In fact, URAC accreditation standards stipulate that the reviewer:

  • Will not receive compensation for the review decision dependent on the outcome of the case;
  • Was not involved in the specific case in question; and
  • Has neither professional, familial or financial ties with any involved parties (the consumer, health plan, treatment facility, etc.) that could be considered leading to a conflict (URAC standards, IR 8).[2]

Even during this time of uncertainty for ACA, the future of the external review process is promising. As transparency issues gain more steam, organizations which choose to proactively engage IROs can feel confident in their decisions, especially by selecting accredited IROs.

ReqQuest provides access to regulatory compliance issues such as transparency and potential conflict of interest concerns. The only regulatory compliance resource of its type in the country, RegQuest is an easy-to-use service that assists medical insurance management in the areas of business, legal and regulatory forces and stays on top of all new federal and state requirements. As a subscriber, you gain instant access to up-to-date information on utilization management (UM), external review (ER) as well as grievance and administrative appeals. With a mouse click you can review state surveys, trend reports, blogs and more.

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[1], pp. 13

[2] Ibid, pp. 12-13

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