Article Surfing Archive

According to the rules established by the Department of Labor and the Employee Retirement Income Security Act (ERISA), every employee benefit plan is required to 'establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination [a denial] to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.' Furthermore, an employee benefit plan must also provide claimants a review that does not 'afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is subject of the appeal, nor the subordinate of such individual.'

Simply stated, under DOL and ERISA, when a benefit plan denies a claim, the claimant has the right to appeal the decision and the review of the appeal must be made by someone who's at 'arms length,' is a like specialist and who was not involved in the initial review process.

To ensure squeaky clean compliance with these regulations and eliminate risks, more and more payers are turning to Independent Review Organizations (IRO) as their outsourced partner for claims appeals. An IRO can help streamline and make the appeals process easier by providing the following services:

Timely, expedited reviews that help you better meet established ERISA deadlines (i.e. Medicare is 72 hours)

Objective, evidenced-based decisions that are supported by medical facts and that can establish whether or not the denied treatment is experimental or investigational in nature, and whether or not the recommended procedureis medically necessary or if there is a lesser expensive alternative

A full panel of medical specialists who are appropriately credentialed with respect to the treatment involved, available to you at a moment's notice and who are not subject to conflict-of-interest issues related to the appeal

Impartial reviewers who can act as an advocate for all parties (the medical provider, payer and claimant)

Healthcare consumers (just like all other consumers) have concerns about the services they receive. Using an IRO as part of the structured complaint resolution process can help appease their concerns and raise overall customer satisfaction. Using an IRO helps you deliver a process to your customers for resolving their concerns in a timely, fair, objective, credible, cost-efficient and defensible manner. Additionally, an IRO can help preserve the patient-physician relationships and allow healthcare providers to participate in the complaint and appeals process on behalf of their patients without them feeling like they may be subject to future discrimination or retaliation. It's a win-win solution for all parties involved in the appeals process.