Independent Review and State Regulations.

Independent review organizations are primarily regulated at the state level. The myriad of regulations makes it a very complex task for an IRO to track. State regulations in turn can be quite difficult to interpret and require an advanced understanding and ability to interpret legal jargon and long, complicated, government documents. The IRO must have an ability to manage, maintain, and anticipate any changes going on at the state level that could change the way in which it must operate. Our view is that these state regulations are very encumbering and we would like to push for a unification of healthcare regulations at the national level that would greatly ease the administrative burden on organizations that are doing business across multiple states. In particular, an IRO like ours which is doing business in more than 30 states needs to maintain a heavy administrative overhead just to track and manage the changes that relate to state regulatory bodies.

We believe that this kind of tracking and management is really wasteful and if a set of national standards would emerge it would make it much easier for us to adhere to one set of standards as opposed to having to manage multiple ones. In any case, the modern IRO must be capable to adhering to all of these standards. It's part of the reason why being an IRO is not a trivial task.

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IROs and Customer Satisfaction

One of the key elements of our business is making sure that we consistently exceed our customer's expectations for quality, turnaround time, customer service, and the other measurements that we have established for our business. Indeed our recent customer satisfaction survey came back indicating that we had better than 85% of our clients that rated us excellent or above average in all major categories. Despite this, it's still not good enough for us.

Our goal is to consistently improve our customer satisfaction. It is that culture of continuous improvement that an IRO needs to have in order to correctly adapt to the demands of today's marketplace. Customer satisfaction translates into many operational initiatives in quality, response time, investment and phone systems, tracking procedures, etc. in order to identify, escalate, and quickly resolve issues so that our clients are completely satisfied.

An IRO needs to be highly responsive to it's customers. One of the distinguishing features of the best IROs is that they have doctors that are available to provide free consultations to their clients over the telephone as a part of their client relationship. Some IROs don't even have in house doctors and rely only on contracted specialists to provide the independent reviews. We found in our business that our clients appreciate us because of our ability to put our own medical staff on the phone with them quickly and consistently to answer their questions while providing that level of expertise and interface, even if we're just translating information from our other specialists on reviews.

An IRO needs to have a commitment to continuous improvement and customer satisfaction. That translates into a variety of investments that need to be made in order to meet the needs of today's health insurance payer.

IROs and Employee Training

Today's IRO needs to continuously invest in training its employees whether it be on clinical procedures, quality metrics, industry trends, administrative procedures, or customer satisfaction improvements. These are the types of training topics that come up regularly inside the organization. In addition to that you have of course ongoing training on privacy, confidentiality, and security issues which are absolutely critical to an IRO's credibility with its clients as well as its own ability to meet federal and state laws.

Regulatory requirements are another area in which an IRO needs to regularly train it's employees in order to keep them abreast of the state regulations that govern independent review. Especially a national IRO like ours, which is doing business in more than 30 states, needs to be attune to this and regularly train and track these requirements with our employees. An IRO, by necessity, is a training organization continuously investing in keeping its people up to date on the latest systems and procedures related to independent review.


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The IRO and Quality Management

IROs are expected to have advanced quality management system much like you'd find in any other organization, which is responsible for delivering a consistent level of high quality to its customers. If you've been in the manufacturing world you've heard of Total Quality Management. The kinds of principles that we've heard and read about for many years in other circles are certainly applying in today's healthcare system. Rendering a consistent evidence based decision is absolutely critical for an IRO as it relates to making sure that it's upholding its two most important goals: maintaining the highest level of quality and patient safety.

Our quality management systems include a number of different types of URAC oriented initiatives. First of all, we track all of our quality data and review it on a regular basis. Second, we have a number of specific measurements and metrics that we use in order to measure how well we're doing as an organization. We track everything from error rate to customer complaints to interior reliability. These are just some of the measurements which are used to ensure make sure that we are consistently delivering quality to our payer and medical management clients.

Quality management systems inside an IRO looks, acts, and behaves very much like a quality management operation in any modern company with an emphasis towards quality assurance. Quality assurance of course relates to taking preventative measures through training, systems development, incentives to employees, and other techniques to make sure that a consistent quality product is always delivered.

Quality control, on the other hand, means checking and catching any errors after they've happened. A good IRO is going to focus on insuring quality by building those upstream systems and processes so that they can prevent those errors from happening in the first place.

Today's IRO has a high degree of accountability to it's clients for quality management and some of the systems and processes that I've mentioned here certainly are things that you should look for if you're thinking about selecting an IRO.

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Independent Review and Turnaround Time

We have a variety of clients across the country who are bogged down with their own administrative procedures and often times by the time they request an independent medical review from us, we only have one or two days in order to perform these reviews. Because of this, we developed our organization to be able to respond very quickly on the to incoming requests. We've lined up a panel of specialists who are well trained and understand that their value to our organization depends upon their ability to drop other things on their day schedule in order to complete reviews for us so that we can get them back on a same day basis or rush basis to our clients.

We have lots of clients that have come to us because our goal is to consistently exceed the URAC specified turnaround times for medical reviews. Right now our organization is averaging one. One day turnaround times for expedited reviews and we consistently average 3 days for standard review even though the standard for that is 3-7 business days. Companies that are looking for fast turnaround times on their independent medical reviews demand that an IRO is capable of meeting those needs. The modern IRO today needs to be capable of providing a service that meets or exceeds those URAC standards.



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medical management