“Consumer education is a key element in understanding the role of an Independent Review Organization and what a medical provider may or may not be responsible for in the review process. Reviewer anonymity is a critical factor in protecting the independent and unbiased status of the medical reviewer in the IRO/appeals process.” — Ed Bolton, CEO and President of Nexus
Typically, employees who face harassment in a workplace setting have someplace to turn, whether that is a supervisor or the human resources department. But for medical professionals in the independent review industry, harassment regarding their opinions is far too common an occurrence and one that leaves these professionals at risk with little recourse for safety, either personally or professionally.
Within the scope of independent review, a dispute may stem from a medical review decision, during which a medical reviewer from an independent review organization (IRO) provides an opinion that assists the health plan in determining whether a consumers’ plan is required to cover a given service or treatment under review.
The medical reviewer, working independently, weighs evidence to render an unbiased opinion on whether the service or treatment in question is medically necessary, experimental or investigational, or meets the criteria for coverage under the plan. The system is designed so that the reviewer works behind the scenes, similar to an independent arbiter, and so that the reviewer does not come in direct contact with the two parties and is not unduly influenced.
In the field of independent medical review, this is known as reviewer anonymity and it is an area of increasing concern among IROs that provide peer review services for the health care industry. Learn more about this concern, among many others, in NAIRO’s latest white paper: Understanding the Vital Role of Independent Medical Review and Utilization Review Services.
“The problem has come to the forefront because our reviewers are getting harassed [more frequently],” says Lisa Ferzoco, Medical Director with MCMC in Quincy, Massachusetts.
Verbal threats, untoward contact persist
Over the past several years, Ferzoco has witnessed medical reviewers come under fire, bearing the brunt of verbal threats and, in some cases, physical intimidation from consumers who are unhappy about the outcome of the review decision.
In one case, Ferzoco recalls one reviewer who received phone calls on a daily basis full of “swearing and threatening” messages, leaving the medical reviewer afraid to go into the office. “We’ve had reviewers threaten to quit over this,” she says.
About 50% of reviewers have received some form of “unwanted communication” from a consumer whose claim was under review, says Ferzoco.
That’s despite mechanisms in place, including nationally recognized accreditation standards and laws governing external review, that seek to shield a medical reviewer from direct contact with a patient whose insurance claim is or has been under review, notes Aja Ogzewalla, CHC, Director of Regulatory Compliance with MRIoA in Salt Lake City.
Ogzewalla points to URAC accreditation standards, which are strict process guidelines followed by accredited IROs, that do not require the disclosure of a review’s identity, name, contact information or any other identifying details.
The majority of state external review laws do not require the disclosure of reviewer identity either, notes Ogzewalla. ERISA, and federal external review laws by extension, and some state laws do mandate the disclosure of the reviewer’s identity upon request.
Independence, anonymity are key
While most states do not require reviewer disclosure at the external-review level, anecdotal reports show that consumers often obtain personal details about an independent medical reviewer from their treating health care professionals, who may offer details unwittingly or may simply try to redirect a consumer’s complaints elsewhere.
That type of disclosure contradicts the very basis of independent review and decision-making upon which external review is built. “Reviewer anonymity helps maintain the independence of the review process,” explains Ogzewalla.
A lack of anonymity may result in other less-than-desired outcomes, including fewer reviewers willing to participate; potential administrative and legal burdens due to unfounded complaints (to a reviewer’s medical board, for example); increased liability and risk to both the reviewer and the IRO; and possibly an influenced final coverage decision.
NAIRO believes that reviewer anonymity is essential to the integrity of the review process and to the safety of the reviewers. URAC-accredited IROs include the board certification and qualifications of the reviewer in the form of a blind biography instead of releasing the reviewer’s personal information.
MCMC has taken steps to coach reviewers “to help minimize the likelihood” of direct contact, says Ferzoco. The internal policy focuses on mitigating contact points, such as using a blocked phone number and emphasizing the independent nature of the review process.
“We’re trying to distinguish the fact that we, as IROs, are making an independent decision,” she says.
Learn more about reviewer qualifications and conflict of interest through NAIRO’s latest white paper here.
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This article was originally published on the NAIRO blog. To read the original publication and follow NAIRO’s blog to find out the latest IRO news.
