External Review Best Practices: 3 Tips

Editor’s Note: Independent review services improve workflow and lower staffing expenses. CLICK HERE for our white paper on the leveraging the value of Peer Reviews for organizational improvements.

Health Plan External Review Best Practices

The Impetus for an External Review

As the ACA Repeal and Replace process sets a new course for healthcare, now is the time for reviewing a quick list of Health Plan Best Practices.  The ACA mandated external review options for all consumers. Continuing this service to consumers sends a positive message about their health plan choice.

External reviews are reviews of a adverse determination to modify, deny, or delay patient care which has been requested.  An external appeal may be requested by the patient, or the treating physician if they do not agree with the health plans initial decision (also called a determination), and allows for patients to have their request for care reviewed by an appropriately qualified, and completely objective third party.

In most cases these reviews are provided by physicians who work for an Independent Review Organization.  The physician, whose treatment expertise and area of practice is aligned with the submitted case, will fully review all medical reports, evidence based treatment criteria, patient and/or physician notes, and all other information related to the case.

A determination will then be made to uphold or overturn the decision.  This benefits health plans as they can avoid costly litigation for complex cases for which there is a dispute, and also provides strict protections for healthcare patients and consumers, who can quickly receive an objective determination as to the care they are requesting once they have exhausted all avenues within the health plans internal appeals process.

Benefits of External Review

Health Plans and Insurance Providers better serve their members if they continue the relationship with an Independent Review Organization to provide independent case determinations.  This assists the health plan avoid costly and complicated legal situations quickly and efficiently without the need to work through a litigation proceeding.

For the consumer, the impartial status for the IRO, reinforces that the member will be treated fairly and that the Health Plan wants a fair outcome for the member.

The Need for External Review Best Practices

For Health Plans and Insurance Providers who now work with designated Independent Review Organizations, there are several areas in which “best practices” can be implemented to ensure appropriate communication, collaboration, documentation, and reporting.

Here are our top three External Review Best Practice Recommendations:

1. Begin With Optimal Documentation

When it comes to clinical documentation, if it is not documented, it didn’t happen.  Equally important is ensuring that as a health plan you have a process in place to get all of this relevant documentation over to the Independent Review Organization as quickly, easily, and with the highest level of integrity possible.  Consider developing an internal checklist of needed documentation for Independent Review, and ensure that every case that is sent for review meets the criteria established within this documentation checklist.  Those health plans and insurance providers who have a process for documentation compilation often see dramatically improved efficiency when submitting cases for review because they are ensuring that they are supplying the Independent Review Organization with all of the details needed to review the case the first time- and every time.

2. Utilize Reporting to Track the Key Metrics from Your IRO

Data is king. The appropriate utilization of data and reporting is the lifeblood for your organization’s future.  Key metrics that every health plan and IRO should be tracking include:

  • Concordance rates
  • Level of Care
  • Review types
  • Case manager submissions
  • Reviewers utilized

The best independent review organizations will work with health plans and insurance providers to generate these reports, and BHM provides these metrics on-demand, so you can pinpoint areas of improvement opportunity within your own organization. Contact BHM for a demonstration by clicking HERE.

3. Seek a URAC Accredited Independent Review Organization

Not all Independent Review Organizations are the same.

There is a high variability within the industry when it comes to network coverage, technology, reporting capability, quality of reviews, and compliance standards.  To take the guess work out of ensuring that you are getting the most capable, credible Independent review organization possible.  Having an organization who has achieved URAC accreditation will automatically ensure that the Independent Review Organization adheres to the highest level of consistent quality standards in the industry.  It will additionally ensure that there are appropriate safeguards against any conflicts of interest, and go further to ensure that physicians working for the Independent Review Organization are trained, qualified, and credentialed to the highest standards.

Independent review services improve workflow and lower staffing expenses. CLICK HERE for our white paper on the leveraging the value of Peer Reviews for organizational improvements.

2017-04-02T13:27:56+00:00 By |Health Insurance, IRO, Uncategorized|

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