Independent Review Organization

A Corporate Integrity Agreement (CIA) is an enforcement tool used as part of a resolution of an investigation into a healthcare provider’s alleged fraud. The provider consents to various compliance obligations in exchange for the Office of the Inspector General’s (OIG) promise not to seek exclusion from Medicare/Medicaid or other federal programs.

If your practice needs assistance, RADMAX has the expertise and experience to be your Independent Review Organization (IRO). RADMAX has experience in Government enforcement support, including serving as an Independent Review Organization, and managing compliance with Corporate Integrity Agreements (CIA).

Our team can provide the following services:

  • Perform independent and objective reviews
  • Perform medical necessity review
  • Perform systems review
  • Perform unallowable cost review
  • Perform review of coding, billing, and claims submission process to Federal Health programs
  • Perform policy and procedure reviews

RADMAX is uniquely qualified to assist facilities and practices in meeting their CIA obligations. Our team has:

  • More than 20 years of extensive experience in the general requirements of the relevant Federal Healthcare programs.
  • Extensive expertise in the substantive issues of medical necessity reviews, systems reviews, and unallowable cost reviews.
  • The ability to design and select review samples utilizing appropriate statistical sampling techniques.
  • Certified Coders with extensive experience in conducting claim audits for medical necessity and appropriateness.
  • A process that follows all applicable Federal rules and reimbursement guidelines in making assessments in the medical necessity, appropriateness, arrangement, and system reviewiews.
  • Sufficient resources to perform the work in accordance with the guidelines outlined in each CIA.
  • Conducted audits with independence, objectivity, integrity, and competence.

All RADMAX employees go through our screening process by performing an OIG/EPLS exclusion search, criminal record background checks and drug testing. New employees also go through an orientation process of our company policies and procedures, standards of conduct, HIPPAA and compliance, etc.

 

FREQUENTLY ASKED QUESTIONS:

Question:  Who can function as an IRO?

Answer:  For the most part, an Independent Review Organization (IRO) is usually a consulting firm, a Billing Company, A CPA firm, or a law firm. The Office of the Inspector General (OIG) does NOT recommend or endorse any particular firm to the provider. However, the OIG does reserve the right to reject an IRO on the basis of qualifications or independence.

 

RADMAX has been assisting members in the healthcare community since 2004, and our team of professionals have extensive background working in various healthcare settings including medical group practices, acute care hospitals and freestanding facilities. The OIG has approved RADMAX as the appointed IRO for Corporate Integrity Agreements (CIA).

 

Question:  What does an IRO do?

Answer:  Most Corporate Integrity Agreements (CIA) require that a claims review be conducted by an Independent Review Organization (IRO).

 

RADMAX will work with the provider to fulfill the requirements of the CIA as they pertain to the duties of an IRO. In most cases, this means that during our IRO audits, we will conduct a claims review, but at times it might be simply a verification review, or the more extensive quality monitor role. There are other activities that an IRO will perform based on that particular CIA. Since RADMAX has experience as an IRO, we can assist the provider in the claims review process, which usually involves the following processes:

  1. The preparation work required prior to the onsite visit or the offsite claims review.
  2. The actual onsite review or the offsite review of claims.
  3. The analysis of the claims review results and the compilation of the IRO report.

 

Question:  Where does the IRO do its work?

Answer:  There are usually both onsite and offsite aspects to an Independent Review Organization’s (IRO) work. In cases where the required documents can be appropriately and effectively provided to the IRO without visiting the provider’s site, the IRO work can be done, and has been done entirely offsite.

 

Question:  When do I need to engage an IRO?

Answer:  Generally within 60 to 90 days of the effective date of the CIA, a provider is required to engage an Independent Review Organization (IRO); however, the specific terms are normally outlined in the Corporate Integrity Agreement. Also, the provider may change an IRO, but must notify the Office of the Inspector General (OIG) within 30 days of the change. The OIG has the ability to reject the selection of the IRO within 30 days of the provider’s notice.

 

When RADMAX is retained to provide IRO services, we work with the provider to prepare them for our activities. We generally have a kick off call to address any questions the provider or staff may have regarding the details or our IRO audits, and what they must do to prepare for us, including timelines. We address any provider questions, and also work directly with your staff to ensure that they are prepared for the required IRO audit.

 

Question:  Why do I need an IRO?

Answer:  An Independent Review Organization (IRO) is often required by the Office of the Inspector General (OIG) under the terms of a Corporate Integrity Agreement (CIA). In addition, beyond the requirement of the CIA, a qualified and independent firm can provide with an objective assessment of your internal systems.

 

Question:  How do I select an IRO?

Answer:  The Office of the Inspector General (OIG) wants the provider to select a firm that is qualified and independent. The Corporate Integrity Agreement (CIA) will contain language which will assist the provider as to the qualifications for an Independent Review Organization (IRO). The OIG also requests that the IRO be professionally independent and/or objective in light of any business relationships or other engagements that may exist.

 

The selection of an IRO can be a difficult and confusing one, particularly, given the stressful circumstances which it must be done. RADMAX has a team of highly qualified and experienced professionals with various healthcare backgrounds. Our goal is to work with the provider to ensure the requirements of the CIA are fulfilled, and to ensure that the experience with us is an educational one and results in a more efficient and effective operation for your practice.

Contact us to learn more about IRO’s.

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