You are reading this for one of two reasons. 

1. You saw a flier in Blue Access for Members^SM (BAM) and clicked for more details.  Or
2. You’re curious about how medical necessity claim disputes are handled.

The BAM page offers the basic answer. Eligible medical necessity claims decisions are subject to independent review.

Now, I am, by nature, a skeptic. If there is a question looming, I am bound to ask it. Total nerd about it. Don’t believe me? I am proud to admit I have raised eyebrows and generated groans for a couple of decades now, but all for good causes:

• Back when I first started writing for researchers, I was thrilled to learn that drug studies had to be reviewed by consumer volunteers (Institutional Review Boards or IRB’s). We had feisty older folks ask really tough questions. You GO Granny! [FDA]
• I loved that the papers I was sending to publish were reviewed by experts. They had no ties to our sponsors. We only ever saw the comments, not who made them. [NIH]. My boss swore he could tell who they were, but his field is small with LOTS of opinions.
• When I worked in continuing medical education on programs for doctors to keep their licenses up to date, I loved finding experts my clients did not know. These experts would tell us what topics and issues were really important. [ACCME]

What is my point with all of this alphabet soup?? Well, if, like me, you read “independent review” and think, “How independent?” then here you go.

We live in a world that takes public health protection very seriously.  We have a long history of rules and processes to help doctors make good decisions. Just like with studies and papers, there are rules for IRO doctors. They are paid for their time spent on the reviews.  Yet they usually do not have ties to BCBSTX beyond that payment.  The same is often true for doctors who take on projects outside of their main job.

IRO doctors look at medical data to make their decision about your claim.  IROs are also subject to oversight just like IRBs and journals and CME providers. [NAIRO]

Yes, knowing this helps me sleep at night. However, not every decision can go to an IRO.

• IRO is not for when you want something covered that is clearly not covered by your policy. Common examples might be:

• Experimental treatments: As a general rule, we do not cover treatments that have not been approved by the FDA. FDA rules about what proves a drug is safe and effective are there for our protection.
• Weight loss treatment: Gastric bypass surgery is not covered by all plans. Even if your doctor says it is medically necessary, an IRO will not review denials based on what a plan clearly does not cover.
• Out-of-network reimbursement: Some plans will cover some charges when members see providers out of network. Members then have to pay the difference between what we pay and what the provider charges. This is why we remind members to confirm their coverage and network before going for visits and care.

• When can an IRO review a case then?

• A claim has to have been denied based on medical necessity. Our medical policy and clinical teams look at all data they can find to make sure our plans cover appropriate preventive, diagnostic, treatment and palliative medical care.

• We look at efficacy: Does data show desired results enough of the time to be chosen as the standard? If we don’t see data to support that, we may not cover that service or treatment.
• We look at safety: Even if early data is good, if there appear to be big risks that go along with those good results, we may not cover that option. We might someday, but not until we see data that convince us.
• We look at cost: If there are options that get equal results, but carry higher costs, we may ask members to try lower cost options first.
• Any of these variables can also be an issue of when as much as what. When something should be done or taken can make a real difference, good or bad, so we keep that in mind.

• It has to have been appealed first.

• Medicine is always changing. The FDA changes policies when new data come out. The National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) and many other schools and professional groups do the same. So when medical necessity comes into question, we want the first chance to review our decision. That’s why the appeal (a process internal to BCBSTX) must come first.
• We still may not change our decision even with an appeal. But what happens when someone gets that unthinkable answer to an appeal? The IRO may be a next step.

• What happens if an appeal is taking too long? What if the treatment in question won’t work (or work as well) after a certain point, and you don’t have an appeal decision? Sometimes an IRO can be used for times like this as well. Check with your plan what the time limits are.

• IRO’s will not end all claim disputes to everyone’s satisfaction. There are few easy answers. Most cases are unique. Some are heart wrenching. We put a lot of effort into doing our best for our members. Just keep in mind:

1. The IRO may agree or disagree with your health plan’s finding.
2. The IRO does not receive any financial benefit based on the result of the review.
3. There is no cost to you for the review.

If you don’t think IRO is right for your situation, check your benefits booklet to see other options for resolving disputes.