Many times in the demanding field of external medical review, the art and science of producing a high-quality report comes with its own set of unique challenges and obstructions.
Independent review organizations (IROs), which provide non-biased reviews of medical coverage and other decisions, often face rapid deadlines, incomplete medical records and what can be a dizzying array of state and federal laws they must abide by.
During a medical review period, IROs must also mitigate potential conflict-of-interest issues and secure adequate medical documentation.
“These various factors, from the onset, impact the quality of the medical review,” says Ed Bolton, CEO of Nexus Medical in New Braunfels, Texas, and Vice President of the National Association of Independent Review Organizations (NAIRO), an industry-leading group of accredited IROs.
But identifying the potential challenges and creating a system or work-flow to address them can augment how IROs handle producing a quality report when under a time crunch or when facing other hurdles over which they have little to no control. The following list enumerates a series of common challenges often facing IROs, according to experts.
Common Challenges in Medical Review
- Facing a rush of rapid timelines. Some states are notorious for issuing a case under difficult circumstances – for example, late on a Friday afternoon – and requesting a three-day turnaround. The three-calendar-day period is a common occurrence, regardless of the submission date, and covers the majority of reviews that come in the door, says Aubrey Longacre, Vice President of Operations at Nexus Medical.
On top of that, more than half – or about 60%, Longacre estimates – of reviews that come in on a Friday afternoon are expected to be turned around in 24 hours. The logistics of securing an appropriate quality reviewer and ensuring all medical documentation is present can make such cases a significant challenge.
- Securing incomplete or missing documentation. In some cases, an insurance provider may deliver some of the information related to a case, but IROs will notice gaps that make rendering a decision a difficulty.
“Making sure all the documentation is in place does create a challenge,” says Terese Giorgio, BSN, MA, LNC, Senior Director of Corporate Programs with IPRO in Lake Success, N.Y. For example, a physician may have additional documentation that doesn’t get submitted. Without all the pieces, “it doesn’t paint a complete picture” of the case in question, says Giorgio.
Tracking down the required documentation can be a time-consuming task, which can delay the medical decision-making and hold up the report. “The IRO should have steps in place to secure the additional documentation,” advises Giorgio. However, in some cases those steps are blocked or delayed, despite intense efforts to overcome them.
- Other issues. The various state and federal rules that govern the medical review process can make some cases problematic. For instance, in a few states the IRO is required to select a medical reviewer who is licensed in that state to perform the external review. The reviewer also must be credentialed in the same specialty as the physician involved in the original coverage decision. That can lead to potential conflict-of-interest issues, notes Bolton. For example, if you’re rendering a decision about orthopedic coverage in a state with a limited number of orthopedists, chances are that many of them have met at a regional conference or through other professional contact. In such cases, the IRO must ensure the reviewer is conflict free with the physician tied to the case, which can prove burdensome in some areas.
In other cases, states aren’t always clear about the type of review in question – for instance, if it’s a case that requires a decision on medical necessity rather than a legal question. Such lack of information can lead to unnecessary delays.
What Can an IRO Do?
First, the IRO can prepare ahead of time as much as possible. Even in cases where unexpected challenges are out of an IRO’s control, having set policies in place can help you maintain forward momentum on a given review. For example, having a process in place to secure missing documentation is paramount.
Also, adhering to the policies set forth in the NAIC Model Act, which is the baseline standard for external review in many states and for federal review, can help IROs maintain a consistent, quality-oriented review process during the external review process. The Model Act requires that specific elements be included in a review, such as an overview or general description of the reason leading to the request for the external review; the dates of receipt and when the review was conducted; and the principal reasons for the IRO’s decision, including evidence-based standards; among others.
In addition, accreditation is a great start because it gives IROs a quality, standardized process, says Bolton. Also, having dedicated compliance staff within your organization is fundamental, and having standards to ensure your clinical staff is highly educated and involved will pay dividends in the long run.