TPA and IRO Partnerships Reduce Claims Costs
Independent review organizations (IROs) work in partnership with third-party administrators (TPAs) to make the best healthcare decisions, more effectively assign medical resources where they are needed and keep health plan costs from rising.
TPAs ensure that all claims decisions are valuable for each patient, but must grant benefits according to healthcare plan language, medical need and the standard of care. Yet most have no in-house medical staff to address questions about medical need or standard of care portion when considering these decisions. When a TPA has a medical director on staff, that doctor is typically a generalist who cannot be expected to have broad and deep medical knowledge of a wide range of healthcare treatments and medical specialties that are constantly changing.
Instead TPAs can work closely with a medical review company, or IRO. This mutually beneficial relationship lets third-party administrators reduce their overhead by not maintaining a medical staff. At the same time, it gives them access to medical specialists with up to date knowledge of the latest medical need and standard of care. By using and IRO, the TPA also can meet all mandated deadlines and allocates its medical and healthcare resources where they are needed, even when making decisions about more expensive and complex medical treatments. In addition, when treatments need pre-authorization, TPAs working closely with an IRO can reduce the number of unnecessary, experimental and out-of-protocol treatments that tend to increase health plan cost.
By partnering with an IRO, TPAs can better manage their case loads and improve their ability to make decisions within required deadlines. Together the two organizations work to allocate medical resources where they are needed, which helps decrease the overall cost of health plans.