Independent Review Organizations Ensure Regulatory Compliance

In today’s highly regulated healthcare environment, it's essential for health plans to make sure all treatment denials are objective and based on medical fact. In most states and the federal government (because of ERISA and Department of Labor Regulations), health plans that deny treatment for patients or members who have appealed a previous denial turn to Independent Review Organizations to assure that they're in full compliance. Health plans must make sure that the decision on the appeal is made by a third party that has no conflict of interest in making the decision. The third party also needs to apply specialty knowledge of a “like” physician to look at the medical chart and make that determination solely based upon the medical evidence. Regulatory compliance is then satisfied.