Independent Review Organization: Internal Review 5.0

IR-INT 4 - Reviewer Qualifications

Submited by: Tom Goddard

The Basics

Under this standard, the IRO must establish qualifications for its reviewers. At a minimum, those requirements must include the following:

  • Current, non-restricted license or certificate as required under U.S. law for clinical practice;
  • At least five years FTE experience with direct clinical care;
  • Must be a clinical peer (i.e., "a physician or other health professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review"); and
  • Have a scope of licensure/certification/experience appropriate to the issue under review. 

Management Tips

The licensure/certification requirement is only for the minimum requirement for clinical practice, not board certification. Board certification is addressed in IR-INT 5.

"FTE" means between 37.5 or more hours per week.

When URAC talks about "clinical peer", it means that, generally, as a peer in a similar specialty, the individual must be in the same profession, i.e., the same licensure category as the ordering provider.

As you craft your policies, be sure to consider the circumstances under which multiple reviewers might be necessary in order to have a clear view of alternative therapies or treatments. 

Accreditation Tips

Desktop Review

A clearly written policy and procedure that outlines not only the criteria for reviewers but how reviewers' experience and licensure will be checked for compliance with those criteria will suffice at this stage of the accreditation process.

Validation Review

Document review

Also as a part of the 30-file review we've already discussed will be an assessment as to whether the peer reviewer for each of those cases meets the IRO's requirements for reviewers.

Interviews

The requirements for this standard will be a part of the interviews of staff handling credentials verification, reviewer assignment, and of the two peer reviewers.

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