IRO Solutions
MCN’s URAC Accredited Independent Review Organization solutions support health plans and payers in the group and individual markets.
The power of a second look.
Initial and Appeal Level Reviews
Prospective, concurrent or retrospective reviews address medical necessity, experimental or investigational treatments, and/or individual plan language. Some are required to determine whether a plan will cover a procedure or can be conducted when a patient appeals a previous denial.
Coding Reviews
Audits on CPT coding practices, reviewing medical records for appropriateness, upcoding, unbundling and other coding concerns.
Formulary Exception Reviews
Addressing whether or not a drug, not currently on a plan’s formulary, is medically necessary in light of the alternatives.
Quality of Care/External Quality Reviews
An aggregated analysis, validation, or evaluation of the quality, timeliness of, and access to services with a provider facility or health care organization.
Independent Provider Audits
Comprehensive, globally-focused audits on a provider’s treatment, documentation, and billing/coding practices across a sampling of patients.
Fraud, Waste and Abuse Reviews
Completed in conjunction with Corporate Integrity Agreements (CIAs) or reviews to assist with Utilization Management or in identifying fraud, waste, and abuse.
Medical Policy Reviews
A policy memo review confirming that a particular treatment or diagnosis aligns with current clinical research and standard of care.
Peer to Peer Discussions
When a specialty matched peer discussion with the treating provider is deemed beneficial.
