Reviewer anonymity is an ongoing issue in the independent review industry. The current industry standard for independent review organizations (IROs) is to prevent the disclosure of the reviewer’s identity unless required by contract, statute, or law. The rationale for maintaining anonymity centers on maintaining the overall quality and integrity of the independent review and maintaining the safety of the reviewer. By allowing the reviewer to remain anonymous, NAIRO believes that reviewers are shielded from undue influence and potential harm. Anonymity allows a reviewer to make the most appropriate decision without outside pressure from other review stakeholders. The National Association of Insurance Commissioners (NAIC) Uniform Health Carrier External Review Model Act (Model Act) and several states have enacted specific language protecting reviewer’s identities and their ability to make unfettered decisions. For example, Section 14 of the Model Act holds IROs harmless for their decisions1. Recently, the Alaska Legislature released Bulletin B 25-05 protecting the identity of IRO reviewers pursuant to AS 21.06.060(f) and (g).
Consumer advocates and treating providers have countered that disclosing a reviewer’s identity allows for additional transparency in the review process. Recently, many treating or attending providers have disclosed reviewers’ identities to stakeholders, including to the insured. Treating providers can access the reviewer’s name from peer-to-peer conversation. In the external review process, the insured is informed of the IRO assigned to their case but does not have access to the reviewer’s name. Information about the reviewer’s qualifications and experience is shared as part of the review decision. In some cases, there have been reported incidents of threats or harassment against reviewers, including actions against reviewers’ medical licenses. As a result of this trend, qualified reviewers may decline to participate in the independent review process, which could severely limit reviewer availability, access, and the overall scope of reviewer coverage from both a geographic and specialty perspective. To offset this potential hazard, reviewers may demand an increased rate of payment to continue to provide IRO reviews. The potential scarcity of reviewers could also force IROs to raise their rates to ensure they can provide appropriate specialty coverage of all review types. Since the insurer pays for state sponsored external reviews in most circumstances, they may pass on the increased cost directly to the insured by raising premiums and related fees.
In the alternative, advocates have opined that the IRO process lacks full transparency and accountability without knowing the identity of the reviewer. The advocates assert that the additional “due process” afforded by knowing who the reviewer is offsets the higher costs or the occasional harassment concerns. NAIRO disagrees and believes that review integrity and reviewer safety are paramount. Dr. Tiffany L. Sanford Robotham, MD, MBA, FACHE, Vice President of Medical Review for iMPROve Health, recently stated that Reviewer anonymity is critical to preserving the objectivity, integrity, and safety of the independent review process. It protects clinicians from external pressures, harassment, and retaliation, allowing them to render fair, evidence-based determinations. Without such protections, reviewer availability could decline, jeopardizing timely access to appropriately credentialed experts. Maintaining anonymity while still disclosing qualifications strikes a necessary balance between transparency and reviewer protection.
In an effort to ensure qualified and appropriate reviewers are utilized and as an industry best practice, many IROs provide a “blinded” biography of the reviewer. This biography includes the reviewer’s credentials, such as board-certification, licensure, years of experience, and areas of expertise. Accredited IROs are bound by the NAIC Model Act to verify the qualifications and expertise of the assigned reviewer. As an additional layer of protection, many IROs require their reviewers to sign an attestation with each review confirming that he or she possesses the requisite credentials and specialty to render an expert opinion. The attestation also requires reviewers to affirm they are in active practice and did not delegate any part of their review decision to another clinician. These qualifications are confirmed via the reviewer credentialing process and prior to assignment. NAIRO believes sharing of detailed reviewer qualifications ensures each reviewer was properly vetted and approved prior to assignment to a review.
1 - Section 14: Hold Harmless for Independent Review Organizations: No independent review organization or clinical reviewer working on behalf of an independent review organization or an employee, agent or contractor of an independent review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization’s or person’s duties under the law during or upon completion of an external review conducted pursuant to this Act, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence.