URAC Releases Revised Independent Review Organization Standards

Dec 30, 2010, 12:55 ET from URAC

Revised Standards Meet Needs From Health Care Reform Changes

WASHINGTON, Dec. 30, 2010 /PRNewswire-USNewswire/ -- URAC, a leading health care accreditation and education organization, has released revisions to its industry-only Independent Review Organization (IRO) Standards, v5.0.  These revisions are part of URAC's commitment to regular comprehensive review of its standards and keeping pace with the needs of the health care industry.

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The Patient Protection and Affordable Care Act (PPACA) increases consumer protections, creates new opportunities for IRO participation and adds requirements for accreditation.  Under PPACA new standards are required for non-grandfathered plans and issuers regarding both internal claims and appeals and external review for plan years beginning on or after September 23, 2010.

In addition, plans and issuers must arrange for external reviews that comply with either an approved State external review process or the Federal external review process.  A State external review process will apply only if the State adopts and incorporates the minimum consumer protections under the National Association of Insurance Commissioners Uniform Health Carrier External Review (NAIC UER) Model Act.  State external review processes require IROs conducting external reviews of internal appeals to be accredited by URAC or another nationally recognized accrediting entity.  States are required to maintain a list of accredited IROs from which they select an IRO to conduct an external review.

URAC's IRO accreditation standards incorporate NAIC UER Model Act standards and ensure that an organization meets minimum regulatory requirements at all times through an ongoing comprehensive mechanism to identify and address new State or Federal requirements.  Among several revisions, the new IRO Standards:

  • Reference back to the NAIC UER Model Act and align with PPACA regulations.
  • Eliminate conflict of interest at the reviewer and organization levels.
  • Promote the use of evidence-based guidelines.
  • Elaborate on credentialing and reviewer requirements.

"URAC accreditation ensures that IROs are utilizing the most appropriate clinical and administrative procedures," said Alan P. Spielman, URAC President and CEO.  "This can both ensure consumer protection and ensure fairness and consistency in health care service decisions."

Companies Seeking IRO Accreditation

There are currently 51 organizations that have earned URAC IRO accreditation or are in-process.  In light of these recent changes, a number of organizations have been working toward URAC accreditation to demonstrate compliance with the new appeal process and become an active participant in the new external review processes for the first time in 2010.  These include:

  • Avysion Healthcare Services
  • C2C Solutions, Inc.
  • The Dyll Review, LLC
  • Exam Coordinators Network ECN
  • Health Care Excel, Inc.
  • Masspro
  • NYCHSRO/MedReview, Inc.
  • Orange County Foundation for Medical Care
  • VHQC

For more information about these revised standards please contact businessdevelopment@urac.org or go to http://www.urac.org.  You can also read more about IRO regulations and accreditation in a URAC issue brief at http://www.urac.org/savedfiles/1URAC_IROIB_2010.pdf.

About URAC

URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation, education and measurement programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. For more information, visit www.urac.org.