Getting Some Legal with Your Medical Review: Indications That Independent Reviews Are Looking Into Clinical And Legal Issues

As medical care and reimbursement rules grow more complex, so does submitting effective appeals. You really need a doctor-lawyer conducting your appeals.

But even if you did, does that guarantee your clinical and legal points would be given full consideration? The wide array of professionals currently involved in appeals – from doctors to medical billing professionals – have often complained that payers give scant attention to clinical arguments and almost none to legal arguments.

However, a recent publication regarding the accreditation process applicable to independent review organizations hints that reviews increasingly attempt to cover both legal and clinical aspects of each denied claim.

“Recently, the health care industry has witnessed an increase in the number of administrative external appeals, which don’t require medical judgment, but instead demand legal review of policies, procedures and applicable law to ensure a health plan is properly applying legal provisions to health care denials. As a result, the need for an IRO is greater than ever because the IRO ensures an independent review of payer practices and decisions in a health care landscape that is rapidly changing.”

This quote appears in a National Association of Independent Review Organization (NAIRO) white paper dated July, 2016, titled “Understanding the Vital Role of Independent Medical Review and Utilization Review Services.”

One of the game-changing features of the Patient Bill of Rights included in the Affordable Care Act was the expanded access to external reviews. One of the concerns addressed by the Patient Bill of Rights was the wide spread belief that insurers have too much financial interest in appeal review and might not be in the best position for judge all information fairly. Therefore, protections were included to guarantee access to external review after internal reviews were exhausted. Although strict requirements for the review guarantees both highly qualified reviewers and decision transparency, the NAIRO white paper points out that consumers are still very uninformed regarding the external review process and safeguards to insure fairness.

“While the scope and role of independent review has grown significantly over the past five years, few consumers utilize this process,” states the publication. “For example, an AHIP study that estimates that less than one out of every 10,000 eligible individuals requested an external review of their denied health claim.”

The paper goes into detail regarding how review organization are typically accredited through a rigorous review process to insure high quality decisions. As explained in the paper, the role of the IRO during the external review process is to be “objective arbiter and determine, based on plan language, evidence-based medicine and regulatory requirements, whether the services in question meet the criteria for coverage under the health insurance plan.”

Plus, decision are typically binding on payer while often leaving consumers with additional redress through the court system.

To accomplish this level of quality review, only top-notch peer reviewers are part of the process and, according to the paper, the panel of experts must include “legal specialists” capable of accessing the legal requirements of the plan. While clinical reviewers must have specified clinical credentials to perform clinical review, it remains unclear what credentials the “legal specialists” must possess. However, adding the term “legal specialists” to the panel provides some degree of hope that the external review will catch issues of legal compliance as well as address clinical issues related to claim review.

While legal reviews are hinted at without being full explored in the paper, the clinical review component of external review is extensively explained in the paper. Reviewers must review extensive medical information including records, recommendations /consults and “the most appropriate practice guidelines.”

However, many clinical questions simply are not definitively decided in medical literature. The process makes clear the reviewers must also have current practice experience in the specialty area under consideration and, if necessary, must reach out to other clinical sources for information. In fact, the paper outlines an almost “dream team” panel which includes the following:

  • Deep expertise and experience. IROs have immediate access to physicians and allied health care practitioners who are at the vanguard of medical treatments and services. Accredited IROs provide expertise in experimental and investigational reviews and are up-to-date on the accepted standards of care.
  • Large panels of clinical reviewers. IROs feature expansive reviewer panels of hundreds to thousands of experts, who can provide access to all recognized specialties and sub-specialties.
  • Affiliations to leading research and knowledge centers. Many IRO reviewers are affiliated with or have relationships with medical centers of excellence and research hospitals, which links them to the latest knowledge and resources of accepted medical practices and treatments.
  • Advanced, ongoing education and training. The training and credentialing programs for IROs are designed to ensure the use of reviewers who are knowledgeable about the most current peer-reviewed literature and evidence-based medicine.

Download the NAIRO white paper at and be ready to explain this process to both your physicians and patients. If you pursue a claim to external review which you feel is largely related to payer legal compliance, we would love to hear about it. Contact Tammy Tipton at with your experience.

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