Improve Your Appeals Decision-Making Process

Many health care organizations have appeals units that are set up to review appeals for benefits denied their health plan members. Often they struggle under the heavy workload related to responding according to state-mandated deadlines for these appeals. Many of these organizations have built up large case management and medical claims departments in order to meet those requirements. They are trying to respond to their case load, but in fact, these health plans are really in another business—and it’s not case review.

When health plans want to improve the quality and speed of their appeals decision-making, they should consider outsourcing these decisions to an Independent Review Organization. Because an Independent Review Organization is much effectively set up to handle large volumes of appeals in a way that is more expeditious and lower cost than a health plan can do so internally. The issue isn’t whether or not Independent Review Organizations have lower cost physicians. They don’t. In fact, we employ many of the top physicians and specialists in the country. The point instead is health plan providers can outsource medical decision making highly qualified physicians on a pay as you go basis—and only pay for a fraction of the doctor’s time at a reasonable hourly rate.

Independent Review Organizations assist a large number of the biggest health insurance carriers today with their appeals decision-making support. Is it time that your organization consider outsourcing this? If you're keeping this kind of work in house and are staffing your organization with a group of doctors to review these appeals, you might want to consider whether it makes better sense for you to send these cases to an Independent Review Organization for external review.

An Independent Review Organization can help you to match each case with a board certified, actively practicing specialist or sub-specialist for every case that comes through your appeals process. This is something that’s very difficult for organizations to handle internally. Even if your organization has a provider arm locating, tracking down, and retaining the services of a specialist to review a case, often times it's very cumbersome them. And it’s not really the business they are in. Instead sending these cases out to an Independent Review Organization that has a pre-selected specialist and sub-specialist panel makes more sense. And it can be done at lower cost and with much speedier turn around times.

Turn around time is a key concern for complying with state insurance regulations, which typically call for an expeditious appeal process. If your organization hasn't begun outsourcing to an Independent Review Organization yet, you should consider investigating the benefits of doing so. You'll find that you'll reduce your cost and you'll improve your regulatory compliances as a result.