The Basics

An excellent starting point for this module is to know how URAC defines "Independent Review":

A process, independent of all affected parties, to determine if a health care service is medically necessary and medically appropriate, experimental/investigational or to address administrative/legal issues.  Independent review typically (but not always) occurs after all appeal mechanisms available within the health benefits plan have been exhausted.  Independent review can be voluntary or mandated by law.

This standard requires that your organization, upon receiving a case for independent review, conducts an initial review of the case.  That review should address four questions:

1. Does an organizational conflict of interest exist?
2. What kind of case is this, medical necessity, experimental/investigational, administrative, or some combination of these three?
3. What is the specific issue that they're referring entity wants us to resolve?
4. Can we handle this case as a standard review, or must we expedite it?

Naturally, in order to address the first question, we need to know what a "conflict of interest" is:

• Any relationship or affiliation on the part of the organization or a reviewer that could compromise the independence or objectivity of the independent review process.  Conflict of interest includes, but is not limited to:
  • An ownership interest of greater than 5% between any affected parties;
  • A material professional or business relationship;
  • A direct or indirect financial incentive for a particular determination;
  • Incentives to promote the use of a certain product or service; 
  • A known familial relationship;
  • Any prior involvement in the specific case under review.

In order to get credit for complying with the standard, your organization no doubt has a policy and procedure that defines conflict of interest.  Be sure you know how to find a policy and procedure and what it says.  Particularly important will be for you to know who makes the determination on initial review as to whether the organization has a conflict of interest, and how he/she makes that determination.

Again, your organization no doubt has a policy and procedure that outlines the criteria upon which the second question (medical necessity versus investigational versus administrative) is decided, and who decides it.  Be familiar with that policy, and particularly how the person or persons making that decision can seek advice on difficult issues.

For the third issue, very often the referring entity will communicate what the issue is that it wants you to resolve.  If the referring entity does not do that, however, your organization should have a procedure that you should know that will determine who within your organization will make that determination and how he/she will make it.

Again, the standard-versus-expedited decision often comes from the referring entity or client.  If it does not, however, your organization should clearly identify in a policy and procedure who within your organization makes that decision and how he/she thinks it.  Be sure you're familiar with that.

Management Tips

There is a lot of pressure on the policies and procedures governing initial review.  They must be clear and completely define the "who, how, and when) of the initial review in all four components of that review.  Particularly important, too, will be the documentation of all of these actions.  As a part of or attachment to your policies and procedures, provide mechanisms to capture the decision-making process on all four issues, whether that involves paper documentation or electronic documentation.

URAC Accreditation Tips

The element requiring a review of conflict of interest is mandatory; all other elements have a weight of 3.

The documentation for the desktop review should include your detailed policies and procedures regarding initial screening on all four elements of this standard.  In addition, any forms you used to document compliance with the four elements of the standard should be submitted, as well.  This would include screenshots of any automated mechanisms for documenting the initial review.

The on-site reviewer will examine your policies and procedures and documentation (electronic or paper) of implementation of the initial review process.  In addition, he/she will interview your staff members charged with initial review and even observe them as they conduct such review to make sure that they are complying with the standard and documenting the review properly.  Finally, this is one of the many issues that will be assessed during the case file audits, so make sure that the files you provide to the reviewer for those audits include documentation of the initial review.