April 15, 2019 – One of the pillars of protecting the integrity of the review process for all stakeholders within the healthcare industry is to conduct secure and prudent clinician credentialing. This is a critical process within the realm of independent review organizations (IRO) and utilization management (UM) organizations.
Vetting and contracting with qualified clinicians is key because health plans and patients rely on the expertise of those clinicians to render accurate reviews. Today, leading IROs and UM organizations are advancing the credentialing process, which largely plays out behind the scenes but is vital to preserving the independence and integrity of medical review.
Some of the important safeguards that members of the National Association of Independent Review Organizations (NAIRO), comprised of URAC-accredited member organizations, adhere to on a continual basis include:
- Comprehensive identity confirmation. Many accredited IROs and UM organizations conduct interviews and perform a thorough examination of a potential reviewer’s history and work files before offering a contract. Some organizations now require that a clinical reviewer provide a notarized government-issued identification. Adding extra security, such as conducting background checks through a state’s Department of Motor Vehicles, can supplement prevailing efforts to confirm the reviewer’s history and, at a very basic level, ensure that the reviewer’s identity is valid.
- Going deeper with background checks. Accredited IROs and UM organizations routinely check with state boards, medical associations, and state and federal exclusion lists to ensure the reviewer does not hold licensing that has lapsed or have any other type of disciplinary actions or sanctions. Additionally, running an Internet search of the clinical reviewer and verifying malpractice history to identify any other issues has become standard practice.
In addition to in-depth identity, sanction, work history, and malpractice checks, many leading IRO and UM organizations have a dedicated credentialing committee, which utilizes an approval-by-consensus approach that further protects the credentialing and re-credentialing process.
Through cyclical processes of refinement and through vigilant standards, NAIRO member organizations seek to use the most qualified, verified and validated clinicians to perform accurate and defensible independent medical and utilization reviews.
For more information about this topic, access the white paper, High-Caliber Credentialing: Protecting the Integrity of Medical Review, that NAIRO released earlier this year. Learn more: www.nairo.org/wp-content/uploads/2019/02/NAIRO-White-Paper-High-Caliber-Credentialing.pdf.