What is an independent review organization?

An independent review organization (IRO) is an organization that reviews health insurance claims in Pennsylvania to ensure that insurance companies are paying the correct amount for medical services. The IRO is an impartial, third-party organization that works with the insurance company and the health care provider to review the medical necessity of services, evaluate any applicable coverage or exclusions, and verify the accuracy of bills. The purpose of the IRO is to ensure that health care providers follow the law and do not overcharge for services. This helps to keep health insurance claims costs down. The IRO also ensures that insurance companies do not deny or delay valid claims. In Pennsylvania, an IRO must have a signed contract with the Insurance Department to act as an independent review. Most IROs are accredited by the National Committee for Quality Assurance (NCQA). To obtain accreditation, the IRO must show that its procedures are consistent with state and federal laws and meet quality standards. The IRO can make recommendations when it believes that an insurance decision was inappropriate, and the insurance company is obligated to follow the recommendations made by the IRO. This helps ensure that health care providers are compensated fairly and that consumers are receiving the best care possible.

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