Independent Review Organization (IRO):  Why Your Healthcare Organization Should Conduct a Mock IRO Assessment.

While inherent to most Corporate Integrity Agreements (CIA), mock IRO assessments are becoming increasingly popular and proving advantageous to healthcare facilities not under a CIA. Conducting a mock IRO using the Office of Inspector General (OIG)-approved methods allows healthcare organizations to identify deficiencies; implement corrective actions; and, proactively conduct auditing and monitoring in accordance with its compliance program. Below are key factors that can help you determine whether your organization should conduct a mock IRO assessment.

Mock IRO Assessment: Why?

The mock IRO is external and therefore provides a healthcare organization with an independent review of potential areas of risk. In addition, the mock assessment can help an organization prepare for or prevent external audits by

detecting vulnerabilities through the use of government audit standards/guidance. This proactive approach provides a healthcare organization with the opportunity to correct identified vulnerabilities and eliminate efficiency, technology and structural integrity concerns.

Mock IRO Assessment: When?

The following key indicators may indicate a heightened need for an external and independent review.

• High risk of denial and/or litigation –During an independent review, the medical need of each case is determined objectively eliminating the appearance of physician bias or financial incentive to an insurer or administrative group. Documentation of the IROs decision-making process can also be used as support during appeal or litigation.
• Possible Questionable Focused Arrangements – IRO review can assess whether your organization is complying with Arrangements Procedures and Arrangements Requirements as defined by the OIG.
• Potential fraudulent or medically unsupported cases – A mock assessment will determine whether necessary processes and accepted medical practices were followed and whether the recommended procedure/s is warranted.
• Shortage of specialists – IROs can provide additional specialized medical expertise and expert knowledge to support claims decisions.
• Increased activity by external auditors – The mock assessment is a proactive approach to understanding potential areas of billing and coding risk, providing the organization with insight into what the external auditors may be targeting.

Provident has served as an IRO and conducted mock IRO assessments for numerous organizations, completing both independent and objective claims, systems and arrangements reviews. For more information, related to IRO and mock IRO services please contact us at contact@providentedge.com.