Instead of contracting with a traditional health insurer to provide group health insurance, many organizations are turning to self-funded insurance plans that are managed by third-party administrators or an outside health management company. According to the Employee Benefit Research Institute (EBRI), about 50 million workers are covered with self-insured group health plans. To help reduce costs and errors associated with these plans, many of these entities are now evolving into “evidence-based” self-insurance plans.
Because self-insured plans are subject to the Employee Retirement Income Security Act (ERISA)–the federal law that protects employees’ retirement income and benefits–the same rights that are available to insureds with traditional healthcare plans are available to individuals on a self-insured corporate plan. This means that when treatments are denied, for whatever reason, the patient has a right to appeal the decision and have it reviewed by a like specialist not involved in the original claims decision. When such a dispute arises, TPAs and self-funded insurance managers are required, by ERISA and state laws, to have questionable cases reviewed by non-biased specialists within specific timeframes.
The primary issue here is how do the management companies, without a full medical panel on staff, decide that treatment decisions are based on proven medical evidence each and every time? How do these companies ensure that they are staying up-to-date with the latest medically approved treatment options?
While some cases are obvious, partnering with an Independent Review Organization (IRO), such as AllMed Healthcare Management, may be just the answer to this issue. An IRO can provide access to the broadest panel of specialists that can make sure decisions are based on proven medical evidence. And, an IRO can also help guarantee state and federal deadlines are met by turning around review decisions within 48 hours or less. For more information on how an IRO can help your organization, please contact AllMed at 800-400-9916.