Independent Review and Mass Customization

When you have hundreds of reviews being done each day and dozens and dozens of clients who are each asking for the reviews to be prepared just slightly differently from each other you can imagine how intricate it is to manage all of those different reviews and customize them according to each client's exact needs. We call this mass customization, which is certainly what is referred to in manufacturing when companies are mass-producing lots of different variants of the same product. Dell computers is probably the best example of a mass customization company who has really mastered this concept. Similarly, IROs also have an incredible ability to mass customize their product and service. The reason this gets done is because each new client has it's own set of parameters that are recorded into the IRO's operating procedures. An IRO needs to be able to mass customize in order to meet the demanding requirements of each of it's different clients.

Why do those requirements vary so much from company to company? Well, IROs are used differently by just about every single type of business. Some companies do first level reviews. Other companies are doing second and third level appeals. Some clients are using us for preauthorizations of medical treatments. Yet again, another group of clients could be looking at us to do quality management reviews. Each of those clients has a different set of needs and the independent medical reviews that we provide for them are integrated into their operations at a different stage of the process. This is why it is so important that an IRO can customize each review to each client’s requirements in addition to meeting demanding turn around times.

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Independent Review as a Highly Optimized Work Flow

We hear about companies that are considering getting into the business of doing independent medical reviews and indeed, on the surface it looks like it's quite easy for any doctor to organize a small panel and start doing specialist reviews for a few clients. The fact is, that in today's environment, an IRO is called to build rigorous processes and standards and the investment required in order to do this correctly to meet the demands of large health plans and other healthcare organizations is very rigorous. I would like to outline in the next several blogs why it is that independent review is not a trivial, easy to organize function inside any organization, and why it requires a significant amount of investment and diligence.

The first thing to know about any IRO is that in order to be competitive they need to have a highly optimized work flow that breaks down the independent review process into a number of standard steps capable of providing a consistent level of turn around time and quality. Today's independent review organization typically has a staff of operations people, clinicians, as well as several software applications, each which have been brought together to organize a workflow that is capable of meeting the turnaround time of our customers.

When 20, 30, or 50 of our clients are calling in review requests that need to be received, dispatched, typed, proofed, edited, and finalized within a 24 hour period, you can imagine how demanding that is on your systems and procedures and how critical it is that your organization has optimized all aspects of the process. We have invested considerable sums of money into integrating our applications, databases, reporting, tracking, data entry procedures, word processing systems, and other aspects of our business including accounting, sales, and customer service in order to be able to provide the level of responsiveness the average health insurance payer or manage care organization needs. The independent review process itself requires an incredible amount of efficient organizational streamlining in order to be effectively and competitive.

The Pressure Cooker of Healthcare Claims Management

We talk to claims adjusters, supervisors, and managers all over the country and the common theme that we hear from them is how increasingly demanding their jobs are and how difficult it is for them to keep up with the workloads that they're facing. In particular, many payer organizations are fighting to reduce costs and look for greater efficiencies.

In the advent of downsizing and layoffs, a lot of claims organizations employees are forced to work twice as hard as they used to in the past. Does this sound like the situation at your organization? If so, one thing you might want to consider doing is employing the services of an IRO where you can outsource your most difficult and complex case decisions.

The reason why you'd want to do this, is because it will make your day go better! If you are a claims adjuster who simply cannot keep up with the level of work that you have on your plate, using an IRO is a way to extend your resources and get more done while making sure that the job gets done right consistently. This is why increasingly Third Party Administrators and health plans are outsourcing their case management to companies that are independent review organizations. You should consider doing the same.

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Consumerism and the Independent Review Process

At the recent URAC Quality Summit in San Diego, we attended several sessions that focused on consumer directed health plans and the advent of consumerism in healthcare was the dominant topic at the conference. As many of you know, URAC is an accreditation body that governs IROs as well as utilization review, medical management, health plans, and other types of organizations in the healthcare sector.

The topic of consumerism is a hot one right now. It really relates back to the whole issue of how consumers are being driven to take a higher degree of responsibility and become more involved in directing their own healthcare decision-making. Why is this? With the advent of high double-digit increases in health care premiums, cost shifting has forced consumers to become more involved in figuring out how it is that they're going to spend their healthcare dollars. Certainly, the advent of health savings accounts and other types of tax advantage plans has also had a major impact on this.

Many people ask us how independent review plays into the consumer driven health plan momentum that is gaining in the United States right now. The fact is that IROs, when providing independent medical reviews and pre-authorizations, are not dealing directly with consumers (or at least very seldomly). However, IROs are the behind the scenes mechanism helping to insure that patients get what they are supposed to get consistently according to plan language, standard of care, and necessity.

Consumerism does not effect the independent review process directly, other than the fact that as consumers become more involved in determining how and where they're going to get their healthcare treatment, there is certainly going to be more conflicts and questions that come up with regard to how those dollars get allocated in the system. This is where an IRO plays a pivotal behind the scenes role in this process. Consumers won’t come to IROs in order to get a claims pre-authorized or adjudicated, but individuals will indeed benefit from the IRO process as it relates to ensuring that patients get what they're supposed to and that subscribers receive the healthcare that they deserve according to the plan language that they subscribe to.

As consumer directed health plans continue to increase, and the independent review process becomes a bigger part of the mainstream of best practices for allocating healthcare resources, we expect the two to converge more and more even if IROs don't deal directly with the public.

Improve Hospital Quality Management - Outsource Peer Review.

If you're a quality or risk management professional inside a hospital you know how challenging it is to keep up with all of the tasks required to manage a quality operation. That's why risk managers today are increasingly looking to outsource non-critical functions to service providers in order to improve quality while maintaining or surpassing standards.

Outsourcing hospital peer review to an IRO is a perfect example of a best practice that is rapidly being adopted by many hospital risk and quality managers. If your hospital is experiencing sluggishness and difficulties in getting its most challenging peer reviews of sentinel events completed in a timely fashion, an IRO can quickly come in and shift that paradigm for you.

We work with many hospitals across the country that have had sticky sentinel events and cases that have been languishing for 6-9 months with no case resolution because they lack available specialist reviewers or a there is some sort of conflict of interest situation. These cases can easily be solved by bringing in an IRO. The IRO can quickly take over those cases, send them out to board certified specialists in active practice in the same specialty area as the cases to be reviewed, process those responses back into a comprehensive report for a single file or multiple charts and return them to the hospital quality management team, typically in less than 30 days. This provides and incredible amount of value to hospitals that are under the gun to meet their requirements yet are struggling with this process.

If your hospital is looking to outsource peer review, my suggestion is think about moving forward with this right away because frankly, hospitals that don't are falling behind in what is becoming a standard accepted practice in the industry.

Making the Right Utilization Review Decisions

As a case manager working in utilization review, you don't want to be denying patients treatments that they deserve. At the same time, you don't want to be preauthorizing expensive and complex procedures that are not within your patients plan language or medical necessity. This is why using an IRO is so important.

It's impossible to know what decision is right in every single case based upon the medical evidence inside the chart. Utilization review professionals simply don't have the time to get all of the facts and work through every aspect of the case before a decision needs to be made and a preauthorization of treatment is allowed. That is why an IRO can greatly expedite the decision making process while ensuring that the decision is made upon the medical evidence and the facts.

If you are a case manager or utilization review nurse and you're not using an IRO to back up your medical decision making, you're not following best practices in today's market place and you could be putting you and your company at risk of making decisions which will end up getting your company into trouble. If you are interested in knowing more about IROs go to the National Association of Independent Review Organization’s website for more information.

Utilization Review Made Easy (Part 2)

If you are a case manager or utilization review nurse, I can really empathize with how much pressure you face in your job to make fast decisions on a myriad of different medical issues and types of cases, without a lot of time for deliberation. Yet, in today's day and age it is even more important for you to be able to make effective decisions and know that you're using the latest knowledge and the latest standards of care in order to back up your determinations. If you are a managed care nurse or a utilization review specialist you can't afford to do this without the backing of a good IRO.

Why is this? The standard of care is too complex. The answers to medical necessity questions are constantly shifting. New technologies are coming online. New treatments are going from experimental/ investigational to standard. As a utilization review nurse you can't possibly be expected to be able to stay on top of all of these changes and shifting standards. Using an IRO and plugging into the specialist knowledge base is absolutely critical to the utilization review function today. That is why most Utilization Review companies and medical management firms have made this a best practice.

Utilization Review Made Easy

Are you a utilization reviewer or case manager who struggles with the moral dilemma of denying patients the care that you believe they should have, even though it's not covered under their plan language? We talk to many managed care nurses who face this dilemma. In fact, some of those people that we talk to have actually left those positions because they're tired of forcing patients to get care which is not substantial enough in order to treat them properly.

If you're a utilization review nurse and having a hard time with this, one way that you can greatly enhance your ability to deliver the right health care and make sure that nobody gets denied treatments that they deserve is by employing the services of an independent review organization (IRO). Why is this? IROs work to ensure that patients get the coverage that they deserve under to the plan language and according to the standard of care and make sure that the patients medical necessity is always put at the highest level of priority when it comes to making those care decisions. IROs employ doctors and physician peer specialists capable of reviewing the details of a patients chart notes and making the right decisions.

Typically, an IRO's default decision when ruling on care decisions is "Yes." Why is this? Because most managed care organizations do want to do the right thing for their patients and their subscribers. Managed care organizations and utilization review companies actually pay IROs to make sure that there is no systematic denial or bias against patients as they make those decisions on health care utilization.

If you're a utilization review nurse or case manager looking to make sure that your patients get what they deserve, consider outsourcing the most complex and difficult cases systematically to an IRO. What you'll find is the consistent application of evidence based decision making at the highest levels, deploying specialists who treat patients in the same area as each case involved. This will allow you to avoid any misgivings about whether or not effective decisions are being made and patients are getting what they deserve.