Internal Medical Peer Review Is Inefficient

As we talk to potential prospects and customers, we sometimes come across health plans, medical management firms, and TPAs ​​who seek to build and maintain their own panel of physicians to do internal medical peer reviews. Earlierly this may have been a good practice for them. But now they need to question whether it's the best practice. We live in the age of outsourcing. In the past, many health care organizations took to organize and deploy all of their resources for all aspects of their business under one roof. Today they are more likely to shed non-strategic, non-core parts of their business, outsourcing them to specialty providers. We believe that independent review organizations are best located to provide medical peer reviews to healthcare organizations.

So if you're a managed care organization, a TPA or a health plan, why would you consider outsourcing to an IRO? Particularly if you've already built a panel of doctors and allied health care professionals to do claims reviews for you?

First, there's a high cost of building and maintaining a panel of specialists who are all accredited, licensed, in active practice and board certified. The function of building and maintaining such a panel can be very cost to an organization that does not have sufficient cases to amortize those expenses over. A managed care organization or health plan is in the business of generating quality outcomes, insuring patients and members and providing them with benefits. Maintaining a large staff of physician specialists is not part of their core competency. If you could outsource the same medical decision-making for a fraction of the cost of doing internally why would not you outsource?

Other elements include the changing standards of care, the new experimental and investigational treatments and how they're impacting medical decision making. It's very difficult for a static panel of physician specialists to maintain expertise about the latest levels of quality of care in all areas of medicine. Medicine is accelerating at light speed with lots and lots of changes in the standard of care, medical treatments and the use of technology. An independent review organization is constantly recruiting and credentialing specialists who have cutting edge knowledge, skill and the ability to apply that experience in reviewing cases. An organization that does not conduct a large number of reviews can not afford the cost of continuing recruiting and credentialing specialists, and there before it can lag behind in its ability to make effective decisions.

An independent review organization also develops a trusted adviser relationship with the managed care organization (MCO), the health plan or the TPA. Over time, the client to garners allows many side benefits from this relationship – in addition to access to an expert panel, obtaining free advice on what to do in particular patient situations and obtaining advanced statistical analysis / reporting from the IRO related to determinations, patient outcomes by population and other tracking systems. As the IRO develops client relationships, it can provide lots of consultation on other issues, such as how to improve plan language in order to make the decision-making process easier, and other similar advantages that help clients improve their business. For this reason, many MCOs, medical management firms, health plans and TPAs ​​turn to independent review organizations even though they've already got their own specialty panels. The cost of maintaining internal peer review panels versus outsourcing medical peer review to an IRO is just too high.

What is your organization doing to improve its competitiveness and reduce its cost of care while improving the quality of its medical decision making? Are you using an IRO yet?

Source by Skip Freedman