Dr. Skip's Medical Peer Review Blog: Helping Third-Party Administrators Manage Healthcare Claims Costs

Saturday, September 16, 2006

Helping Third-Party Administrators Manage Healthcare Claims Costs

Independent Review Organizations work with Third Party Administrators across the nation to deliver better care decisions and allocate healthcare resources more effectively.

Why is an Independent Review Organization so important to this process of working with Third Party Administrators? It's simple. First of all, third-party administrators are called upon to ensure that effective claims decisions are made for each patient and that benefits are allocated according to plan language, medical necessity as well as standard of care. Yet third-party administrators typically do not have the in-house medical staff to perform this function. So they need to rely upon the services of an outsourced medical review company, or Independent Review Organization, to make these determinations effectively. As a result, third-party administrators depend heavily on Independent Review Organizations for allocating medical and healthcare resources regarding the most expensive and most complex medical treatments.

Usually should a Third Party Administrator have a medical director on staff, typically they are generalists and cannot be expected to have medical knowledge across a whole spectrum of different types of healthcare treatments and medical specialties. This is where employing the services of an Independent Review Organization can make a huge difference in terms of improving an organizations ability to make those decisions. This is also why third-party administrators today rely heavily on Independent Review Organizations to get their medical reviews done fast and efficiently.

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