IRO Decisions Balance Health Plan Payouts Against Patients' Need for Care

LANSDALE, Penn., April 29 /PRNewswire/ -- Independent review organizations (IROs) are evolving as important intermediaries that balance payers' and patients' rights says NAIRO, an organization of IROs.

For the payer, IROs help health plans make better evidence-based healthcare determinations for patients while helping to manage plan costs. For plan enrollees, IROs help ensure that each member receives the coverage stipulated by a plan.

"IROs cannot monitor health plans or guarantee an enrollee treatment, but we help balance the needs of the healthcare payer with those of the plan enrollee by providing up-to-date medically-based evidence about a treatment," says Joyce Muller, NAIRO president. "Ultimately, this is good for our healthcare system, because it means better coverage for patients and lower costs for payers."

IROs often interpret the health plan language and consider how it compares with evidence-based medicine and the accepted standard-of-care. This practice assures that patients receive the care they need and protects payers from excessive costs.

It's well known that many health plans exclude cosmetic surgery. However, sometimes a procedure that might be cosmetic for one person can be medically necessary for another. For example, an IRO might find that:

"When weighing the medical evidence and insurance benefit, IRO opinions often provide payers with specialized medical insights they can't otherwise afford," says Muller. "This assures that their enrollees receive evidence- based opinions about the medical necessity of a treatment and at the same time can save health plans money."


Formed in 2000, NAIRO works to promote the value and integrity of the independent medical review process, as a key part of the solution to America's healthcare crisis. Its members embrace an evidence-based approach to independent medical review to resolve coverage disputes between enrollees and their health plans. For more information visit


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