Independent Medical Review and Emerging Standards of Care

It's no secret that we're dealing with an always changing playing field with emerging medical treatments and what is accepted as being a standard of care. Indeed right now we see a shift going on as it relates to the medical necessity of beriatric surgery which, as everyone knows, is a quite complex and very costly treatment procedure for obesity. A few years ago this procedure was being denied systematically by most health plans, and today it's coming into the mainstream of treatment and being more consistently embraced by health plans as a remedial measure for treating patients who have tried but failed at diet and exercise.

An Independent Review Organization needs to stay abreast of these changes as they are happening and adapt its decision making criteria and processes in order to make sure that the decisions rendered on independent medical reviews meet those changing standards of care for medical necessity. Treatments that were once experimental or investigational are moving in the direction of being medically necessary as well. In areas such as cancer treatments we see a number of new types of medicines coming out and being moved through the FDA approval process and then into the mainstream of cancer treatments. An IRO needs to have specialist as well as tracking systems, databases, and information libraries which allow it to continuously evolve its decision making criteria to what is medically necessary in accordance with movements in modern medical thinking.

healthcare
medical management
independent medical review