Independent Review Expands Its Scope: Case Studies in Context

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Led by accrediting bodies, leading IROs deliver a greater breadth of services.

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Once limited to reviews of medical necessity, today’s accredited IROs possess the expertise and commitment to deliver medical review services across many diverse settings.

Independent review is a critical component for ensuring the use of appropriate evidence-based health care along the continuum. Health plans, consumers and other invested parties benefit from the expertise of accredited independent review organizations (IROs) at multiple touch points within the health care system.

As a core function, IROs provide objective, evidence-based physician review services. IROs often settle questions of medical necessity. Yet backed by expertise, they do much more.

By leveraging the standards of URAC accreditation (a prerequisite for NAIRO members) and the expertise of vast panels of physician advisors, today’s leading IROs are able to deliver far-reaching review services in many facets of health care – including pharmacological review, disability review, hospital peer review and more.

NAIRO, a nonprofit association, represents IROs that have sustained URAC accreditation, an industry benchmark that exemplifies the highest standards of quality and sustained excellence. Within the health care industry, an IRO acts as a third-party medical review resource, providing objective, unbiased medical determinations and conflict-free decisions that help clinical and claims management professionals better allocate healthcare resources.

This Issue Brief explores the diverse roles of IROs in today’s complex health care ecosystem, and explains the functions, expertise and core services that make accredited IROs the leaders in independent review.

Case Studies in Context: The Expertise of IROs

The following areas provide a snapshot of IRO expertise across diverse settings.

Pharmacological Reviews

IROs provide pharmacy reviews when there are questions concerning a patient’s pharmaceutical prescriptions, e.g., their appropriateness, whether they meet appropriate treatment guidelines and standard of care. These evidence-based reports help clients ensure a safe and cost-effective pharmacological plan.

Hospital Peer Reviews

Hospitals use IROs to supplement their internal peer review committee processes, to perform case reviews as a follow-up to adverse outcomes, and for credentialing and privileging purposes. Quality, performance improvement and risk managers turn to IROs to overcome conflicts of interest, to deal with sensitive or legal matters and to help evaluate specialties which are difficult to assess with internal resources.

Disability Peer Reviews

These reviews include short-term disability, long-term disability, pension disability, return to work assessments and FMLA. IROs are utilized to determine if the subjective and objective evidence provided supports functional impairment and work restrictions. Although medical necessity of treatments is not considered part of a disability claim, NAIRO member organizations have found that URAC accreditation has become an unofficial industry standard in performing such reviews. This is due to the high credentialing and organizational performance standards required by URAC.

Workers’ Compensation

Many different laws govern the workers’ compensation system with requirements varying by state. Utilization review (UR) is heavily regulated in workers’ compensation. IROs are viewed as an excellent resource for physician advisor reviews imbedded within a carrier or TPA’s utilization review program. IRO accreditation requires strict adherence to state and federal regulatory standards. Because IROs are accustomed to incorporating and exceeding regulatory requirements, and maintaining vast panels of specialty-matched physician advisors, they deliver a valuable combination of expertise. IRO physician advisors provide evidence-based opinions of necessity, appropriateness, causality and relatedness of treatments and services utilizing appropriate treatment guidelines.

As the above case examples show, NAIRO members are committed to protecting the integrity of the independent medical review process in all health-related disciplines. Once limited to reviews of medical necessity, today’s accredited IROs possess the expertise and commitment to deliver medical review services across many diverse settings.


NAIRO (The National Association of Independent Review Organizations) was formed by the majority of URAC-accredited IROs. The mission of NAIRO is to promote the quality and integrity of the independent review process at the internal and external levels. Utilizing the expertise of board-certified clinicians throughout the country, NAIRO members embrace an evidence-based approach to independent medical peer review, in order to help resolve coverage disputes between enrollees and their health plans. More information can be found at

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