IRO Core 3.0

IRO CORE 33 - Financial Incentive Policy

Submited by: Tom Goddard

The Basics

This standard says, essentially, that if the organization has a system by which people are provided financial incentives that are based directly on consumer utilization of healthcare services, there must be mechanisms in place to make sure that these incentives don't end up compromising consumer care. This policy includes capitation of providers. Not all URAC reviewers over the years have interpreted this standard this way, so it is helpful to get official clarification on this sometimes controversial issue.

Management Tips

You'll need to assess all your compensation systems at all levels -- staff, management, contractors, and vendors -- to make sure you're thinking broadly enough about this standard. If you do identify bonuses or incentives that trigger this standard, you'll need to make sure you have one or more methods of making sure that consumers are not underutilizing health services as a result. Reviewers can be pretty rigorous in examining these methods for assuring your consumers are receiving adequate care, so don't cut corners here.  

Accreditation Tips

Desktop Review
If you do not have financial incentives, provide both a P&P prohibiting them and a senior executive attestation that you do not and that, if you ever do, you'll first develop mechanisms for assuring that consumer care is not compromised.
If you do have financial incentives related to consumer utilization of health services, make sure you describe them reasonably completely, and then make absolutely sure you document your consumer utilization oversight mechanism. Once this standard is triggered, the reviewer will be looking closely at how you assure there is no resultant underutilization, so you may as well document it thoroughly up-front.
Validation Review
Interviews
During the onsite review, the key will be in the interviews. The people in charge of the utilization oversight mechanism will need to provide reassurance to the reviewer that the methodology is sound, related to the incentives, and likely to detect any problems with consumer utilization.
This is a mandatory standard, so make sure you get it right!

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