Which types of organizations use an IRO to provide independent medical reviews or peer reviews? Many companies can benefit from this type of service.

Foremost are health plans and health insurance carriers that require an IRO in order to make sure that they adjudicate claims in a properly.

Second are third party administrators (TPAs) that administer benefits and claims for health plan payers.

Third are reinsurers or stop-loss carriers. Stop-loss carriers use independent review organizations as a way to assure that they are getting a second objective and unbiased opinion for their most expensive and complex medical claims that they are called to provide coverage for.

Fourth are large self-insured corporations that pay their own health care benefits. They are increasingly turning to IROs in order to help with their claims decision making.

Fifth are managed-care organizations that are providing preauthorization point of care determinations for their patients.

Sixth are utilization review companies. They use IROs to preauthorize complex, special and costly treatments.

Utilization management companies and business units inside larger firms also use IROs. Medical management companies use IROs routinely to outsource their claims decision making and preauthorization of treatments. Union trusts also turn to Independent Review Organizations to make sure benefits are properly administrated for their union populations.

All of these organizations work in the health care space to provide either payment services or preauthorization of treatments. There are other types of insurers that also use independent review organizations in order to administer claims. Disability insurance carriers, their TPAs and medical management firms also use IROs as well as workers compensation carriers, their TPAs and medical management firms. Property and casualty firms that are paying out medical claims also turn to independent review organizations to review claims. Fraud units working inside larger health plans and special investigative units use independent review organizations to look at the medical necessity of treatments and validate or to root out potential provider fraud.

As you can see, many different types of organizations in different markets turn to IROs as a critical source to decide, adjudicate and authorize health care claims. IROs today are an accepted best practice by the largest and the smallest organizations that participate in managing care for patients today.