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Keeping External Reviews Free from Conflicts of Interest

March 13, 2017

Although the rate of appeals is low, mitigating potential and actual conflicts of interest is a critical issue for Independent Review Organizations (IRO). A conflict of interest severely damages the integrity of the independent review process, both for internal and external reviews. Thus, transparency between stakeholders is important to maintain this review integrity.

Generally, both states and accredited IROs consider it a conflict of interest if the same IRO reviewer, and in many cases the same IRO, performs both the internal and external review on a particular appeal. It is our understanding that no URAC-accredited IROs will accept an external review request of an appeal when they have already reviewed the claim as an internal appeal. Additionally, most states will not assign an external review request to an IRO that has had previous involvement with the case.

Steps to Mitigate Conflict of Interest

Most IROs take the following steps to avoid potential conflicts of interest:

·         Organizational and staff conflicts are checked upon receipt of a review from an assigning entity

·         Potential reviewer conflicts are checked prior to assigning the case for clinical or legal review

·         Accredited IROs use the Model Act and URAC standards as their guidelines to identify conflicts

·         If an organizational conflict or staff conflict is found, the IRO will notify the assigning entity for resolution

·         If a reviewer conflict is discovered, the assigning entity will be notified and the case will be assigned to a reviewer that does not have a conflict

However, it should be noted that several states do not consider the presence of a pre-existing contract with an insurer to perform internal review to be a conflict. Washington, California and New York are the only states that have defined those terms. Per their definitions of “material financial affiliation,” it is only a conflict of interest if a contract generates more than five percent of the total annual revenue or total annual income of an IRO or an individual director, officer, executive or reviewer of the IRO.

The majority of the states considered to be ‘NAIC-parallel” by the CCIIO[1] have adopted the conflict of interest language from the NAIC Model Act,[2] which states, “the IRO and the clinical reviewer assigned to conduct an external review may not have a material professional, familial, or financial conflict of interest with the following:

  • The issuer or plan that is the subject of the external review
  • The claimant (and any related parties to the claimant) whose treatment is the subject of the external review
  • Any officer, director, or management employee of the issuer; the plan administrator, plan fiduciaries, or plan employees
  • The healthcare provider, the healthcare provider’s group, or practice association recommending the treatment that is subject to the external review
  • The facility at which the recommended treatment would be provided; or the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended.”

The National Association of Independent Review Organizations (NAIRO) published a paper in 2015 outlining steps to take to ensure that a review does in fact remain independent and without conflicts of interest. The group suggests that the best way to eliminate any possibility of conflicts of interest during a medical reviews process is to use accredited, compliant IROs.[3]

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[1] CCIIO. Affordable Care Act: Working with States to Protect Consumers. Retrieved from: https://www.cms.gov/cciio/resources/files/external_appeals.html

[2] NAIC. Uniform Health Carrier External Review Model Act, Section 13: Minimum Qualifications for Independent Review Organizations, Subsection D (1-2). Retrieved from: http://www.naic.org/documents/committees_b_uniform_health_carrier_ext_rev_model_act.pdf

[3] NAIRO. “Accredited, Compliant IROs Lead the Way to Fair and Transparent Medical Review,” Oct. 14, 2015. Retrieved from: http://nairo.org/news/nairo_position_paper.en