Independent medical review
Encyclopedia
Independent medical review is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether or not there was any mis-diagnosis, mistreatment or any systemic problems involved which lead to the sentinel event.
Physicians who perform independent medical reviews must be board certified and in active practice in that same area of treatment. These physicians are contracted by an independent review organization, medical management companies, third party administrator
s (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity
, if there was a sentinel event, what was the reason for it, etc.
Physicians who perform independent medical reviews must be board certified and in active practice in that same area of treatment. These physicians are contracted by an independent review organization, medical management companies, third party administrator
Third party administrator
A Third Party Administrator is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. This can be viewed as "outsourcing" the administration of the claims processing, since the TPA is performing a task traditionally handled by the...
s (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity
Medical necessity
Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds...
, if there was a sentinel event, what was the reason for it, etc.
See also
- Case management (USA health system)
- National Association of Independent Review Organizations
- Utilization managementUtilization managementUtilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan...
- URACUracURAC, formerly known as the Utilization Review Accreditation Commission, is a nonprofit organization promoting healthcare quality by accrediting healthcare organizations.- Mission :...
- Utilization review