Caution: Push for Expedited Medical Review Services Can Compromise Review Quality

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.

How IROs Deliver Value

Working nationally, accredited independent review organizations (IRO) are outfitted to provide objective determinations of medical claims. Board-certified physicians and clinicians working for accredited IROs provide evidence-based decisions to approve or deny medical claims based on clinical standards and accepted standards of care. For life-threatening situations, IROs deliver expedited medical review determinations – typically, within 72 hours.

Yet some state regulations and other policies are moving to further reduce expedited review timeframes. The reduced expedited review timeframes should only apply to urgent circumstances, such as the truly “life-and-limb” situations. IROs are fully capable of helping states determine what is an urgent situation requiring a reduced expedited timeframe. In Nevada, for example, an IRO is required to “complete its external review not later than 48 hours after receiving the assignment,” unless other terms are explicitly agreed upon, according to the state’s managed care regulations. In Michigan, the “Patient’s right to independent review act” limits an IRO’s length of time for which it can confer a coverage recommendation to 36 hours.

Medical review experts working within the industry are witnessing the trend to reduce expedited timeframes firsthand.

“It seems like the industry is seeing more requests for expedited reviews,” reports Valerie Aiello, Vice President of Healthcare with Healthcare Quality Strategies Inc., a URAC-accredited IRO. It’s not that accredited IROs can’t maintain a high level of quality standards when working expeditiously – in fact, that’s what they must do to maintain URAC accreditation.

“IROs are well-equipped to handle [expedited reviews] from a quality standpoint,” Aiello says. “The whole purpose of using an IRO is for a timely review. But expedited reviews should be allocated solely for emergent or life-threatening situations.”

A host of critical factors may arise when an expedited review is assigned, and that may compromise the quality of the medical review process. Concerns surrounding expedited reviews include:

  • Insufficient time to contact parties involved, including the patient and/or provider, when it is necessary to collect additional medical records to render an accurate and complete review. This could lead to patients and providers feeling they were not treated fairly or given adequate time or opportunity to submit details in support of their case.
  • Inadequate time for reviewers to identify and evaluate issues under review.
  • Not enough time to conduct a thorough literature search and to apply all necessary peer-reviewed literature.
  • Reviewers may be hesitant to take cases on such short notice and/or require a much higher fee to perform the review.
  • Lack of time to perform an adequate review may lead to an increased uphold rate.

Due in part to the fact that URAC-accredited IROs are held to a set of stringent, high-quality standards, meeting the growing chorus of calls for rapid review services is not always manageable in reality. For instance, accredited IROs use clinical reviewers who are in active practice, and it would be detrimental to patient care to expect a medical review determination to disrupt healthcare delivery.

The URAC accreditation standards also require that clinical reviewers meet a high bar. For instance, reviewers must hold an active U.S. license; have recent experience or familiarity with the current body of knowledge and medical practice; and have at least five years of experience providing healthcare. The focus on quality is a net win for independent peer review services – but it also limits the availability of physicians who can turn around reviews in a day’s time.

Another hurdle worth mentioning is the system within which medical review takes place. Independent reviews occur within the confines of what can be a chaotic healthcare system, in particular when it comes to care documentation and medical records.

“There’s a conceptual belief that faster is more qualitative,” says Paul Gilleece, Vice President of Peer Review for URAC-accredited MCMC, LLC. “But there are pitfalls to doing appeals too fast. Going too quickly can have a negative impact.” This is particularly true for the enrollee.

Often, when IROs are staring down a request for expedited review they are faced with factors beyond their control. Important pieces of documentation and supporting materials are not always available within the electronic medical record. The need to track down missing documentation that’s critical to a review determination can take time and resources. Making a decision without sufficient medical records can be detrimental to the review and ultimately the enrollee.

Most state regulations don’t build such flexibilities into their medical review policies. Instead, they tend to follow an ill-advised rule of thumb that the clock starts when the case is sent to an IRO, and in some states when the Department of Insurance receives the appeal, not when the IRO acknowledges receipt, confirms a clinical reviewer has been assigned or has received all the information necessary to complete the review.

Given the concerns expressed above, the National Association of Independent Review Organizations (NAIRO), a body of URAC-accredited IROs, believes that 24- to 48-hour expedited review timeframes should be used solely for life-threatening situations, and all other expedited cases should be 72 hours.

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