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NAIRO Calls on California to Eliminate Onerous ‘Duty of Care’ Provisions in UR Bill

California Senate Bill (SB) 636 could jeopardize the vitality and integrity of the independent utilization review process, and the National Association of Independent Review Organizations (NAIRO) stands firmly against the bill’s provisions pertaining to “duty of care” mandates.

The current version of SB 636 – “Workers’ Compensation: Utilization Review,” introduced by Senator Dave Cortese – would “require employers establishing a medical treatment utilization review process to ensure that utilization review physicians have the same duty of care to an employee as a treating physician.”

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Tech Solutions Rapidly Emerging for Review Orgs, With Potential for Big Returns

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.

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Technology Enhancements in the Medical Review Process

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).

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

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


Table of Contents

I. Introduction

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No Surprises: IROs Set to Excel Within ‘Surprise Billing’ Dispute-Resolution Process

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.

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Why Cyber-Liability Coverage Is Essential for Medical Review Organizations

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.

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President Calls for Strengthened Mental Health Parity in Annual Address

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.

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Mental Health Parity Law in Calif. Signals Shift in Review Industry

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.”

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