IRO stands for independent review organization. This type of organization is present in many industries, providing peer review and judgement of a person 's work product, performance, or related behavior. The use of IROs has become a leading practice in the medical field in the past few years. It is a way to get an objective third party decision on medical cases.
Why are IROs important in today 's healthcare world?
Healthcare IROs have the responsibility to determine whether a healthcare service is appropriate and medically necessary, or if it is experimental or investigational. In terms of healthcare, an IRO is an option for a patient who has gone through all appeal options available in the health benefit plan. It offers an independent opinion that can sway the insurance
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Some states have guidelines which meet or exceed the federal guidelines. In those states, the insurance companies follow state law. In the states that don 't have guidelines which meet the federal standards, the U.S. Department Health and Human oversees the external review process.
What about IROs in the state of Texas?
The state of Texas has an external review process which meets federal guidelines. In fact, many years ago, Texas mandated that all health plans accepting patients in the state must agree to let those people appeal to a certified independent review organization, when the insurance company is refusing to pay for a healthcare service.
The results have been startling. One study found that 55 percent of Texas patients who filed an IRO appeal received additional treatment. That means the insurance company 's denials were either partially or completely overturned. In the case of mental health treatment, the percentage went up to 70 percent.
The IRO reviews found that healthcare insurers had large gaps in their coverage and their guidelines for determining which treatments were acceptable or not. This helped the state enhance its requirements for basic healthcare coverage for