Ensuring reporting mandates and regulations are met accurately and on time
Understanding What an IRO Does
MCN is a URAC-accredited Independent Review Organization (IRO). We provide specialty-matched, unbiased reviews meeting all applicable URAC, state, and federal mandates within appropriate time frames. Our expert reviewers, drawn from across more than 90 specialties, answer questions on medical necessity and experimental or investigational treatments — as well as on medical plan language and policy applications. MCN adheres to strict conflict of interest and privacy policies.
As an IRO we deliver Utilization Reviews, which generally either assist health plans/insurers in determining whether a specific plan offers coverage for certain treatments and procedures, level of care, or other administrative issues such as legal and clinical interpretations of medical policy and contract language eligibility.
Initial and Appeals Level Reviews
Initial and Appeals Level Reviews, a type of Utilization Review, address whether a plan will cover a procedure, or when a patient appeals their plan’s denial of coverage. Reviews may be pre-certifications or be completed concurrently or retrospective to treatment.
Federal law mandates that the third level of appeals reviews — External Reviews — be completed by a URAC-accredited IRO — such as MCN. Many aspects of External Reviews are strictly governed by the Patient Protection and Affordability Care Act (PPACA), or through individual state laws. Determinations made in an external review are final and legally binding.
Additional Review Types
MCN providers a full range of review types, and is able to customize services for each client. Types of reviews include:
- Coding Reviews — Audits on CPT coding practices, reviewing medical records for appropriateness, upcoding, and service details.
- Formulary Exception Reviews — These address whether or not a drug that is not currently on a plan’s formulary is medically necessary in light of the alternatives.
- Fraud, Waste, and Abuse (FWA) 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 Conversations — Reviewer calls to treating providers; related notes are part of the report.
- 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.