IRO | Decision Making

In any industry and, in some regards, in any life –  there are times when an outside perspective is the difference between progress and an impasse. In the world of healthcare, where often the bottom line of organizations can be at odds with the wants and needs of the patients and payers, a third-party perspective can help to untangle the web of miscommunication.


IRO | An Unbiased Opinion

An Independent Review Organization (IRO) can provide this perspective by weighing both sides of healthcare decisions through the use of several specialist physicians who can provide unbiased review of a particular hospital’s situation. IROs have to wear multiple hats to serve different clients – while payers need IROs to review their coverage of services, physicians, patients and hospitals need IROs to review trouble spots on a case-by-case basis and evaluate the documentation.


IRO | Expertise

Expert physicians with a wide breadth of experience can look at patient charts and assist IROs with identifying gray areas that may be causing the hang-up in payment from insurers. And, of course, with the internet allowing patients to have up-to-the-minute information of their conditions and possible treatments, it’s more likely that patients won’t take a physician’s recommendation at face value.


Of course, it’s not enough for payers to take patient’s rights and needs into account – the bottom line for everyone in healthcare in the modern world is to reduce costs – anywhere and in any way possible. Because of this, IROs are also charged with evaluating costs and juggling the rights of the patient.


IRO | Where They Came From

IROs arrived on the scene when the Affordable Care Act was enacted several years ago and the provisions of the ACA are expected to continue well through the next several years. The impetus for outsourcing IROs was to, as with other provisions of the ACA, reduce cost and improve quality simultaneously. Since IROs are designed to fulfill the review function, they can process far more claims in a given time frame than an organization could on its own – while it may seem counterintuitive to outsource something that could, potentially, be handled in-house, the scale of claims that can be processed externally is far greater.


Other benefits of an external IRO?


  • Standard set criteria guides decision-making
  • A large pool of experts who have varied professional experience
  • Unbiased assessment
  • Reviewers from all over the United States available
  • Frees up medical directors and other administrators to concern themselves more with the tasks at hand that affect direct patient care and carry less administrative burden
  • Pertains to medical necessity – of particular importance with the coming of ICD-10
  • Providing clarification and necessary exceptions to cases that deviate from the norm – example? Cosmetic surgery would normally not be medically necessary, but in some cases, such as in reconstructive surgeries that restore function, they would be classified as necessary.
  • Find yourself on the cusp of new technology, research and the very best medical care available.
  • Know that you are compliant at state and federal leaves – put your mind at ease!

Deciding on an IRO, however, can be tricky – so make sure you know the facts about all that you are considering before you take the leap.