So what is the role a medical director of an IRO (Independent Review Organization) plays?
That is a very good question which does not have a simple answer.
I have tried to think of a concise answer each time one of my medical colleagues asks me what I do!
There is a short answer and several long answers.
The short answer is “A Medical Director for an IRO oversees the medical and clinical policies and decisions submitted by the IRO.”
While this accomplishes the goal of being a short answer it probably falls far short of succeeding in transferring much understanding.
So the next step is to expand the explanation to a bit more detailed answer.
It is probably best to begin with one of the various functions of an IRO and then to examine the role of the medical director.
A major function of an IRO is to provide “Independent External Medical Reviews” for insurance companies.
This occurs when a medical or surgical treatment has been denied by an insurance company and an independent external review is requested.
As a URAC (Utilization Review Accreditation Commission) accredited IRO, Medical Review Institute of America, utilizes a panel of over 600 board certified specialist to provide independent medical reviews.
One of the key responsibilities of a medical director is to function as a liaison to the medical panel and to provide feedback to the reviewers (positive as well as negative).
Another responsibility of an IRO medical director is to provide guidance to the “Internal Medical Team.” This team consists of physicians and nurses who review the “completed external reviews” before they are sent to the client. The reviews are evaluated for quality, and clarity of the summary, explanation of findings, conclusion, and references. There is scrutiny to be sure that the questions are answered as asked and that appropriate plan language, policy language, and pertinent guidelines are utilized. The answers are evaluated for rationale and consistency, and the quality and appropriateness of the references are evaluated.
This is just a portion of the responsibilities of an IRO medical director.
So much for a concise answer!
No wonder my medical colleagues tend to ask “So what is it that you do?”
Ben Buchanan, MD, MBA, FACEP, Medical Director