IRO's and Medicaid Expansion
The Importance of IROs with Medicaid Expansion
According to the Association of Health Insurance Plans (AHIP), more than 72 million Americans rely on Medicaid and CHIP for reliable, quality healthcare. A total of 37 states have voted to expand Medicaid services over recent years, which has given healthcare coverage to an additional 10 million people. With expansion across numerous states, the demand has increased for companies specializing in Medicaid services.
In the health insurance arena, a handful of plans are opening up who focus on serving patients in government programs, such as Medicaid and Medicare. For larger health plans, many have merged to focus on coordinated care, social determinants of health (SDOH) and value-based payment arrangements to reduce costs for Medicaid patients. On the flip side, enrollment in commercial employer-sponsored plans has remained flat. This growing Medicaid membership has companies rushing to fill the void of managing Medicaid services and claims.
The Benefits of an IRO
With more lives being covered, that means more opportunities for independent review organizations (IROs) to assist health plans with medical peer review. Being in the IRO business, I’ve been focused on Medicaid expansion and the growing opportunities with these newer, smaller plans specializing in Medicaid. Most of these health plans don’t have an IRO partner in place — making room for a mutually beneficial partnership.
A third-party reviewer, like an IRO, can offer numerous benefits to Medicaid plans. With smaller plans, serving anywhere from 50,000 to 100,000 lives, they likely only have one or two Medical Directors in-house and in a small range of specialties. For cases that are outside of their purview, an IRO can offer their resources and access to board-certified physicians, actively-practicing in a wide range of specialties. Especially with federal and state-mandated regulations, an IRO is able to source physicians for specialty-matched cases that otherwise may not be possible to perform in-house.
One of my efforts that I’m very passionate about is to improve pediatric care. With case reviews, pediatrics is often underserved in health plans. Medicaid expansion has included the growth of the Children’s Health Insurance Program (CHIP), which currently has 9.6 million children enrolled. Like other medical care, there’s a demand for case reviewers with specific pediatric specialties, as opposed to a general pediatrician. An IRO can offer assistance with various pediatric specialists or sub-specialists to fit any need.
Another benefit an IRO can offer a Medicaid health plan is specialized customer service. At MES Peer Review Services (PRS), we provide simplified rationales accompanied by our case reviews. [JW1] For Medicaid health plans, a clinical rationale for the outcome is required along with a simplified version to send out to their members and providers in their approval or denial letters. This extra step we provide is an added bonus of utilizing an IRO.
Making the Most of Medicaid Expansion
Watching Medicaid evolve has kept me on my toes by changing my sales approach to fit industry trends. My advice is to get in with the emerging Medicaid companies and show them the importance of an IRO. Don’t limit yourself to the big household names in the group health arena. Look at the health plans who have emerged post-Affordable Care Act (ACA), and become their initial IRO partner. Then when that company grows, you’re already on the ground floor and will grow with them. Staying ahead of the curve, because Medicaid will only continue to expand, is the best place to establish a relationship.