You are reading this for one of two reasons.
The BAM page offers the basic answer. Eligible medical necessity claims decisions are subject to independent review.
Now, I am, by nature, a skeptic. If there is a question looming, I am bound to ask it. Total nerd about it. Don’t believe me? I am proud to admit I have raised eyebrows and generated groans for a couple of decades now, but all for good causes:
What is my point with all of this alphabet soup?? Well, if, like me, you read “independent review” and think, “How independent?” then here you go.
We live in a world that takes public health protection very seriously. We have a long history of rules and processes to help doctors make good decisions. Just like with studies and papers, there are rules for IRO doctors. They are paid for their time spent on the reviews. Yet they usually do not have ties to BCBSXX beyond that payment. The same is often true for doctors who take on projects outside of their main job.
IRO doctors look at medical data to make their decision about your claim. IROs are also subject to oversight just like IRBs and journals and CME providers. [NAIRO]
Yes, knowing this helps me sleep at night. However, not every decision can go to an IRO.
If you don’t think IRO is right for your situation, check your benefits booklet to see other options for resolving disputes.
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