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WHAT IS INDEPENDENT
MEDICAL REVIEW?

Peer review, independent medical review, hospital peer review, and medical peer review, have all become interchangeable terms in the healthcare industry. As is often the case, different organizations and individuals use their own vocabulary when talking about the same thing. In general, the term “Peer Review” has become a simplified substitute for all these phrases.

Whatever term is applied, the core function is to obtain the objective determinations of physicians who are not a party to a particular treatment. They can approve or deny medical claims based on medical evidence, and accepted standards of care. These physicians must be board-certified and in active practice.

Independent review typically (but not always) occurs after all appeals mechanisms available within a health benefits plan have been exhausted. Independent review can be voluntary or mandated by law.

 

 

ORGANIZING THE INDUSTRY

While URAC has developed evidence-based measures and accreditation programs for independent medical review since 1990, their charter as a standards body precludes ties to any industry-interest group.

In 2001, Dr. Winifred Hayes led efforts to form the National Association of Independent Review Organizations, or NAIRO. The primary objectives of NAIRO are:

  • developing guidelines for solving common industry problems,
  • promoting standards for these reviews,
  • educating consumers about their rights for claims appeal,
  • helping define the role of IROs in the evolving healthcare landscape.

Since its formation, NAIRO has assisted policy makers at both the federal and state level with position papers and analysis of issues. NAIRO has also helped its member organizations demonstrate the value of URAC accreditation and their processes for independent medical review.

NAIRO LEADERSHIP

NAIRO is a member-driven, non-profit association. NAIRO Officers are elected to a two-year term by ballot of member organizations with voting rights. These Officers, along with the Executive Director and the previous NAIRO President, form the NAIRO Executive Committee.

Aja Ogzewalla, CHC

President

Ms. Ogzewalla is Director of Regulatory Compliance at Medical Review Institute of America, based in Salt Lake City, UT. Her experience in collaborating with URAC, the US Department of Labor, and the Employee Benefits Security Administration is part of her industry expertise on legislative and regulatory issues, standards revisions, and court opinions affecting the IRO industry.

Ed Bolton

Vice President

Mr. Bolton is Chief Executive Officer of Nexus Medical, based in New Braunfels, TX. He founded Nexus Medical in 2009, and is a retired US Army veteran with two decades of executive experience in healthcare. His recent efforts include development of the NAIRO white paper “Understanding the Vital Role of Independent Medical Review and Utilization Review Services” in 2016.

Melody Petrul, RN

Secretary

Ms. Petrul is Director of Medical Review Services at MPRO, based in Farmington Hills, MI. She oversees Medicaid fee-for-service (FFS) review contracts and all independent review services. She also leads efforts for review staff education, physician credentialing, internal and external quality improvement and medical records management.

Gib Smith

Executive Director

Mr. Smith is an independent management consultant, based in Purcellville, VA. He has been Executive Director of NAIRO since October 2008. Prior to NAIRO, he served in positions with MAXIMUS and MCMC, backing his three decades of experience in the IRO industry.

Julie O'Brien, RN, BSN, MS

Former NAIRO President

Ms. O’Brien is President of AliCare Medical Management, based in Salem, NH. She has been in various executive positions with AliCare since 2002. Prior to AliCare, she served as Director of Clinical Services for Health Dialog, and was Administrator for Neurology at Massachusetts General Hospital.

Join NAIRO

Want to help shape independent medical review regulations, provide URAC accreditation feedback, network with industry influencers, and more? Do more with NAIRO.