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Payer's Edge - How IROs Help Payers Optimize the Medical Director's Role

Blog: The Payer's Edge

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HOW IROs HELP PAYERS OPTIMIZE THE MEDICAL DIRECTOR'S ROLE

In today's ever-changing health care landscape, the role and responsibilities of Medical Directors have been stretched beyond the traditional clinical scope. As the scope and complexity of their roles continue to evolve, payers of all types are increasingly partnering with IROs to perform medical review at all stages of the care management continuum. Learn more about how IROs are helping to streamline the utilization review process, easing pressure on medical directors while allowing organizations to work more effectively and efficiently.

In today’s ever-changing healthcare landscape, the role of Medical Directors at health plans, TPAs and medical management organizations is expanding at a rapid pace.  As the scope and complexity of their roles continue to evolve, payers of all types are increasingly partnering with IROs to perform medical review at all stages of the care management continuum, including pre-authorizations, internal appeals, provider quality reviews and more. Health plans can leverage independent review organization (IRO) resources to help their medical directors maximize their value-added, while upholding the integrity of care management decision making.

Challenges Faced by Today's Medical Director

While the title “Medical Director” has remained unchanged, their responsibilities have expanded dramatically over the past two decades. Traditionally, a medical director’s duties had an internal/ clinical focus, with an emphasis on utilization review, case management, appeals, and quality oversight. The main driver was ensuring quality of care while controlling over-utilization.

Today however, medical directors find themselves in a unique leadership position, with a broad scope of responsibilities and increased external focus. Evolving duties include significant involvement in strategic planning, business development, financial analysis, and operational efficiency. This expansion of duties has been added to other responsibilities that involve clinical quality improvement, provider oversight, utilization management, network design, medical policy development, accreditation and credentialing oversight, care delivery, and collaboration with other organization leaders.  

In addition, medical directors must still perform their core functions, including medical case review, using their clinical experience to make determinations regarding medical necessity, coverage, the quality of care, and the continuation of inpatient care.   It’s not uncommon for medical directors to review 50 or more cases per day, and the volume of reviews to be performed on top of other duties can be overwhelming.

This has led to long workdays, increased administrative burden, and ultimately burnout. Organizations expect medical directors to be involved in numerous activities, such as those described above, along with serving on multiple committees, visiting practitioners and hospitals, all while being responsible for time-sensitive cases without coverage from peer physicians. Appeals reviews can become repetitive and time-consuming, while pre-authorization reviews present one more burden.

Partnering with IROs Allows Medical Directors to Focus on Higher Value-Added Work

Within healthcare payer organizations, medical directors are some of the highest paid employees. At these levels, organizations are looking to optimize the work of their physician leaders by focusing them on strategic initiatives. Offloading physician pre-authorization reviews to an IRO allows medical directors to focus on higher-level, value-added work that is more strategic.

This includes developing medical policy, chairing committees, providing oversight to the quality management program, leading performance improvement initiatives, supervising utilization review and case management personnel, adjudicating complex claims, participating in appeals processes, and so on.

A recent survey of chief financial officers and business office leaders found that outsourcing of complex claims reviews helped to improve internal productivity.

Additional Advantages of Outsourcing to an IRO

Outsourcing physician pre-authorization review also gives payer organizations the ability to reduce fixed overhead and align physician review costs to actual volumes. Whether there is a barrage of incoming cases, a seasonal lull, or physician vacations, an IRO partner has the resources to properly allocate clinical staff to meet a variable workload. Since an IRO is focused only on providing medical review services, it optimizes cost and streamlines the process of physician recruiting and credentialing, medical review workflows, and all ancillary activities. In addition, since it handles much larger volumes than many individual payer organizations, an IRO is able to spread overheads across a large volume of cases.

Partnering with an IRO is an efficient and defensible way to properly manage a health plan for both the insurer and the patient. As unbiased advocates, IROs ensure that every patient gains the coverage they deserve for complex or controversial cases, while eliminating overutilization.

Outsourcing: A Straightforward Strategy to Ease the Burden

Continual changes in health care have shifted and stretched the role and responsibilities of medical directors beyond the traditional clinical scope. Partnering with an IRO for first-level physician review is one of the most straightforward strategies to address the constant pressure that medical directors face. Additional drivers for a health plan’s decision to outsource the physician review portion of their utilization management operations include cost, strategic focus, technology, volume fluctuations, and turnaround time. IRO partners help to streamline the utilization review process, easing pressure on medical directors while allowing organizations to work more effectively and efficiently.