Technology solutions are fast-emerging in the clinical peer review space, from workflow tools that can streamline the medical review process to systems like natural language processing and machine learning that can unleash layers of efficiency.

While artificial intelligence-fueled technology, such as ChatGPT and Microsoft’s Bing chatbot, has grabbed headlines in recent weeks, it’s fair to wonder if AI is entering the medical claims review arena. Although it may be a tantalizing thought, experts say it’s not quite there yet.

While a full-fledged vision of artificial intelligence (AI) remains an elusive conquest within the healthcare industry, rapid advances in technology are showing the ability to improve workflow, enable faster decision-making and, overall, deliver a boost to medical review companies and affiliated stakeholders.

When it comes to new-age technology in healthcare, AI is still in a “science fiction” phase, says Ed Bolton, CEO and president of Nexus, a URAC-accredited independent clinical review and utilization management company based in Schertz, Texas, and immediate past president of the National Association of Independent Review Organizations (NAIRO).

Understanding the Vital Role, Challenges, and Opportunities of Independent Medical Review Services

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Table of Contents

I. Introduction

Effective January 1, 2022, the No Surprises Act (NSA) ushered in sweeping changes to the dispute-resolution process between healthcare providers and payers, establishing a “baseball-style” arbitration system in which an independent arbiter settles payment differences for out-of-network (OON) charges.

The federal independent dispute resolution (IDR) process, which generally applies to group health plans, health insurance issuers offering group or individual health insurance coverage and Federal Employees Health Benefits (FEHB) carriers, includes the certification of IDR entities to make payment determinations.

As ransomware and other types of cyber crime grow increasingly prevalent, it is paramount that organizations in the medical review and utilization review space know how to best protect their business and client operations with adequate levels of cyber-liability insurance.

A growing area of coverage – yet one that can prove challenging to obtain or afford – cyber-liability insurance doesn’t prevent ransomware attacks and data breaches from occurring, but it provides a high level of defense against downstream risks. Most cyber-liability policies provide network security and privacy liability, limited protections against network business interruptions, media liability provisions and limited coverage of legal expenses.

A federal effort to confront escalating mental health issues – including a refocus on mental health coverage parity – was a central part of President Biden’s State of the Union address that he delivered to lawmakers March 2.

The United States is facing what the White House calls an “unprecedented mental health crisis.” Accelerated by the COVID-19 pandemic and the resulting worry, isolation and depression, mental health issues today impact every two out of five adults and an increasing number of children and adolescents.

A mental health parity law that took effect in California on January 1, 2021, means that independent review organizations (IRO) and utilization review organizations (URO) can expect to work with new care guidelines when assessing coverage standards.

Senate Bill (SB) 855 is one of several pieces of legislation to appear in recent months aimed at improving mental health coverage and addressing perceived disparities in the breadth and extent of coverage. Similar laws, including Illinois House Bill 2595, require that health insurers adhere to standards of care developed by nonprofit organizations, rather than the more traditional commercial standards.

The Illinois bill, for instance, requires that “an insurer shall exclusively apply the criteria and guidelines set forth in the most recent versions of the treatment criteria developed by the nonprofit professional association for the relevant clinical specialty.”

With voters in five states passing ballot measures to approve the use of medical or recreational marijuana, the 2020 election cycle shows that the trend of relaxing laws surrounding cannabis continues to gain traction.

 

Fair IDR: The Way Forward To Protect Patients & Resolve Surprise Medical Bill Disputes

Protecting patients from surprise medical bills is a national concern.¹ The stories of financial hardship placed on patients from surprise medical bills, whether due to lack of coordination in our health care delivery system or misaligned billing practices of health care organizations, are well told. In fact, over 57% of American adults have received at least one surprise medical bill.²

Independent medical peer review services are a fundamental part of the U.S. health care system, providing valuable, evidence-based decisions on medical claims.

However, there is an emerging trend that is pushing for faster medical review determinations, particularly in the event of non-acute and non-emergent situations. This trend can potentially compromise the quality of independent review services for the intended beneficiary – the enrollees.

The act of surprise billing – when a patient receives an unexpected medical bill, sometimes for thousands of dollars or more – is a common occurrence within the American health care system. Studies show that roughly 20% of surgical patients receive a surprise bill, at an average of $2,000 in non-covered fees.

Though states are responding differently to the COVID-19 public health emergency (PHE), current stay at home orders in many regions and the hesitation for companies and employees to return to the office have brought attention to a previously under-the-radar element of business continuity. Namely, the potential for operational disruptions brought on by situations where your workforce cannot attend the office, or where your office is forced to close.

Accreditation and certification organizations have varying requirements to respond to the disruption of normal business, whether it is called business continuity, as in the case of URAC, PCI, or HITRUST; Disaster Management (NCQA); or Business Continuity Management (ISO). Emergency situations that can trigger a WFH business continuity model might be anything from the current PHE to prolonged power outages, severe weather, earthquake damage or other disruptive situations.

ALBANY, NY – February 28, 2020, – The National Association of Independent Review Organizations (NAIRO), the nation’s leading voice of independent medical peer review, is pleased to announce its annual Educational Symposium on April 28-30, 2020 at the Kiawah Island Golf Resort in South Carolina.

The NAIRO Symposium offers two days of networking and in-depth education, with sessions focusing on a range of topics relevant to the independent review of healthcare claims.  The event’s 2020 theme is “Protecting Review Integrity During Healthcare and Regulatory Evolution,” and will highlight changes in the healthcare and regulatory environment and their subsequent impact on Independent Review Organizations, Workers’ Compensation Organizations and Health Utilization Management Organizations.

We are very excited to present the all-new NAIRO website and association management platform! This website will help with the work of keeping our membership connected. With social networking support, simple tools for staying in touch, space for sharing documents and photos and resources to support committees, we can use it to help market our association and highlight great work being done.

In addition, NAIRO.org is going to be the workhorse that will collect member dues and support event registration and payment.

We are excited to officially announce NAIRO’s 2020 Symposium – Protecting Review Integrity During Healthcare and Regulatory Evolution. Please mark your calendar for April 28-30, 2020 and plan to join us at the beautiful Kiawah Island Golf Resort near Charleston, South Carolina.

The 2020 Symposium is an opportunity for us to discuss the latest developments and trends in independent medical review. Attendees will be able to take advantage of in-depth educational content and professional development, and network with others in our industry. Save the date, and stay tuned for additional details regarding registration and sponsorship!

ALBANY, NY – June 17, 2019 – URAC and the National Association of Independent Review Organizations (NAIRO) support Congressional legislation to protect patients from “surprise billing.”  This practice has placed financial hardship on patients due to the lack of coordination in our delivery system and the misaligned billing practices of healthcare organizations.  If Congress considers adoption of an arbitration model whereby an independent arbiter decides any payment disputes between health plans and providers, we believe that the arbiter(s) should be accredited independent review organizations (IROs).  Payers, providers, and their regulators deserve an independent, qualified assessment regarding a payment determination.  Accredited IROs have a 20-year history of protecting patients by serving as trusted independent clinical experts.  Accredited IROs have a strong foundation avoiding conflicts of interest, utilizing high-qualified and specialized clinical reviewers and staff, and rendering accurate and timely decisions in a transparent manner. New York, New Jersey, and Illinois have all found success utilizing the arbitration model.

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ALBANY, NY – June 10, 2019 – The National Association of Independent Review Organizations (NAIRO), the nation’s leading voice of independent medical peer review, is pleased to announce the newly installed Executive Officers of its Board of Directors.

NAIRO’s 2019-21 Executive Officers include:

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.

New white paper defines the highest standards in vetting medical reviewers

ALBANY, NY – February 15, 2019 – Today the National Association of Independent Review Organizations (NAIRO) released a publication showcasing the key concept of clinician credentialing within the wider scope of independent medical review and utilization review.

The white paper, High-Caliber Credentialing: Protecting the Integrity of Medical Review, identifies the rigorous standards that leading independent review organizations (IROs) and utilization review/utilization management (UR/UM) organizations adhere to when vetting clinicians for important decision-making activities related to appropriate health coverage.

ALBANY, NY – February 4, 2019 – The Board of Directors is pleased to announce that the National Association of Independent Review Organizations has selected Capitol Hill Management Services as the new firm for managing the association.  “We are pleased to have a proven national leader in association management to help NAIRO improve our association’s administrative and membership services, grow our membership, and increase awareness of our organization across the United States,” said Board President Ed Bolton.

“Through its committed members and outstanding programs, the National Association of Independent Review Organizations is playing an important role in protecting the integrity of the independent review process for all stakeholders” said John A. Graziano, Jr., President of Capitol Hill Management Services.  “We are pleased to work with the association’s dedicated Board of Directors and volunteers in ensuring a successful future for IROs and helping to improve healthcare delivery through the effectuation of a fair and equitable review process.”