Dr. Skip's Medical Peer Review Blog: Claims Management Made Easy

Wednesday, September 06, 2006

Claims Management Made Easy


If you're a claims manager or adjuster workers comp, auto, health or disability insurance, one of the scarcest resources you have is your time. When you have complex and costly cases, your time gets eaten up adjudicating claims and consulting others for opinions. If you find yourself in positions where you're stretched too thin, a great way to extend your capabilities and to move your most difficult cases through your organization is to use the services of an Independent Review Organization. Independent Review Organizations are dedicated to providing medical decision support to claims payers of all types on healthcare benefits or on medical benefits related to specific treatments. An Independent Review Organization provides an external, objective medical review service for insurance carriers, Third Party Administrators, and other types of payers. Independent Review Organizations help them allocate their resources effectively and provide decisions about the approval and denial of treatments.

Independent Review Organizations are typically accredited by a URAC (at least the good ones are). They provide a panel of external peer physicians in all specialties and sub-specialties who are capable of providing standard or expedited reviews of health care cases by determining their medical necessity, standard of care, whether they are experimental or investigational, whether they indicate an appropriate length of stay in hospitals and other types of questions that a doctor must review.

The Independent Review Organization always matches the case with a specialist having the same background as the referring specialist. Independent Review Organization specialists are always board certified, licensed and in active practice. This insures is that you will be able to use the same expert knowledge to make your claims decision as was originally applied to the treatment being considered. It allows you to speed up your claims decision making, eliminate unnecessary medical treatment, reduce premium costs for disability and workers comp and ensure that your claims resources are being allocated to members who deserve the care, and not those who don’t.

So if you're a claims manager and you're not using an Independent Review Organization today to evaluate claims inside your organization, consider one.

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