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.

A doctor wearing a white coat and stethoscope, sitting at a wooden desk, writing in a notebook. There are medication blister packs, a smartphone, and notebooks on the desk.

Coding Reviews

Audits on CPT coding practices, reviewing medical records for appropriateness, upcoding, unbundling and other coding concerns.

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Formulary Exception Reviews

Addressing whether or not a drug, not currently on a plan’s formulary, is medically necessary in light of the alternatives.

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External Reviews

A final binding review at the State or Federal level to evaluate a treatment or service denied by a health care organization. This process ensures an objective and impartial assessment to determine if the denied service was medically necessary or appropriate.

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Medical professional discussing brain scan results with a patient in an office setting.

Independent Provider Audits

Comprehensive, globally-focused audits on a provider’s treatment, documentation, and billing/coding practices across a sampling of patients.

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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.

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Medical Policy Reviews

A policy memo review confirming that a particular treatment or diagnosis aligns with current clinical research and standard of care.

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Quality of Care

An evaluation of health services to determine if they meet established professional standards with focus on the structure of care, process involved, and outcomes achieved.

Peer to Peer Discussions

When a specialty matched peer discussion with the treating provider is deemed beneficial.