News & Events

The National Association of Independent Review Organizations (NAIRO) is actively involved in the issues surrounding the independent medical peer review industry. The following links provide an information source for recent and upcoming news and events concerning the NAIRO organization and its objectives.

IRO Decisions Balance Health Plan Payouts - Against Patients’ Need for Care

Evidence-based medical decisions push standard-of-care forward

Lansdale, Penn. — April 29, 2008 — Independent review organizations (IROs) are evolving as important intermediaries that balance payers’ and patients’ rights says NAIRO, an organization of IROs.

For the payer, IROs help health plans make better evidence-based healthcare determinations for patients while helping to manage plan costs. For plan enrollees, IROs help ensure that each member receives the coverage stipulated by a plan.

“IROs cannot monitor health plans or guarantee an enrollee treatment, but we help balance the needs of the healthcare payer with those of the plan enrollee by providing up-to-date medically-based evidence about a treatment,” says Joyce Muller, NAIRO president. “Ultimately, this is good for our healthcare system, because it means better coverage for patients and lower costs for payers.”

IROs often interpret the health plan language and consider how it compares with evidence-based medicine and the accepted standard-of-care. This practice assures that patients receive the care they need and protects payers from excessive costs.

It’s well known that many health plans exclude cosmetic surgery. However, sometimes a procedure that might be cosmetic for one person can be medically necessary for another. For example, an IRO might find that:
• Breast reduction is medically necessary for a woman with excessively large breasts that cause her back pain.
• Refractive laser eye surgery is needed by a firefighter intolerant of contact lenses when wearing glasses would pose him a job risk.
• Eyelid surgery is required if a patient has visual interference at 20 degrees above horizon and taping their eyelids back improves his vision 20 degrees above the horizon.

“When weighing the medical evidence and insurance benefit, IRO opinions often provide payers with specialized medical insights they can’t otherwise afford,” says Muller. “This assures that their enrollees receive evidence-based opinions about the medical necessity of a treatment and at the same time can save health plans money.”

About NAIRO
Formed in 2000, NAIRO works to promote the value and integrity of the independent medical review process, as a key part of the solution to America’s healthcare crisis. Its members embrace an evidence-based approach to independent medical review to resolve coverage disputes between enrollees and their health plans. For more information visit www.nairo.org.
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Media contact:
Martin Middlewood
Frontline Strategies Inc.
360.882.1164
martinm@pacifier.com Read more »

Patient Rights Extend to Independent Review - Most state legislatures—43 states and the District of Columbia—have passed some form of Patients’ Bill of Rights act. Among other things, this act gives patients’ the right for an independent review if their healthcare case is denied.

This right is important, because healthcare-plan providers often deny treatment based on issues other than the medical necessity of a treatment. Just a few of these reasons include out-of-date exclusions, ambiguous plan language and meeting financial objectives. In addition, often health-plan business goals are in conflict with their service delivery.

However, this is not a David and Goliath contest any more. According to an article in Parade magazine by Lori Andrews, a health law professor at Chicago-Kent College of Law, 50 percent of the patients’ challenging their denials get them reversed and independent medical review organizations (IROs) are helping these patients get the treatment they deserve.

Often licensed and URAC accredited IROs like those involved in NAIRO review denial claims and reverse them based on current literature. One purpose of NAIRO is to offer unbiased medical decisions about healthcare treatments for health plan providers and consumers so that the appropriate healthcare plan providers can deliver care to those who are paying for it. Read more »