The Office of Inspector General (OIG) has negotiated hundreds of Corporate Integrity Agreements (CIAs). Under a CIA, a provider or entity consents to certain defined obligations in return for the OIG’s agreement not to seek an exclusion of that health care provider or entity from participation in federal health care programs. The OIG does not have the resources to directly monitor all entities under a CIA and therefore, requires each provider to hire an Independent Review Organization (IRO) to ensure compliance with the terms of the CIA. The OIG leaves the selection of the IRO entirely up to the organization. However, the OIG reserves the right to block an IRO within 30 days after identification based on IRO qualifications or an inability to carry out IRO duties under the CIA. All responsibility for selecting a properly qualified IRO firm falls upon the entity.
There is great latitude in deciding upon an IRO. Virtually all reviews under CIAs are performance reviews, not financial audits. It is advisable to commence the IRO selection process once negotiation of a CIA begins. If the decision is delayed until after signing, providers risk not having enough time to properly identify and vet prospective firms. Once the search begins, there are a number of ways to identify prospective candidates. An internet search offers one avenue to find firms who possess expertise in carrying out the responsibilities of an IRO. Another method involves checking with similar organizations that are operating under a CIA to learn about their experience with their IRO.
Factors to Consider When Selecting an Independent Review Organization (IRO)
Qualifications: Can the proposed IRO actually perform the tasks outlined in your CIA (e.g., reviews of claim processing, cost reports, arrangements with potential referral sources, marketing practices, drug pricing, etc.)? Does the IRO have sufficiently qualified personnel suited to the organization or provider’s size, complexity, needs and sophistication?
Capability: Does the proposed IRO have a track record within the same sector of health care? Do they have deeply experienced staff to ensure continuity throughout the term of the CIA? An organization should avoid incurring expenses by helping a potential IRO firm learn their trade.
Resources: Can the proposed IRO effectively staff a five-year long engagement and maintain continuity of staff? Can the organization demonstrate its financial viability as an organization? Does the firm have professional liability insurance of at least $3-5 million?
Operational Experience: How long has the firm operated in the health care sector? It is advantageous to have a highly experienced firm that can evidence success in the health care sector over time.
IRO Specific Experience: Does the firm have extensive experience in performing IRO work? With hundreds of CIAs in force, many firms have performed these services on many occasions. It is not unreasonable to look for a firm that has served as an IRO a half dozen or more times. An experienced IRO will be able to manage reporting effectively through clear, consistent and efficacious communication with both the provider and the OIG. The more experience, the better.
Professionalism: Does the proposed IRO have the sophistication to handle all the issues, especially in complicated cases? Can the proposed IRO work with credibility with the organization and the OIG to clarify or smooth out issues that may arise during the term of the CIA? A properly experienced IRO will know how to handle complicated issues appropriately in a timely manner.
Cost: Are the proposed IRO’s costs and charges competitive? It is wise to obtain at least three proposals to assess the range of costs for the proposed scope of work.
Referrals and Reputation: Do the potential IRO’s references provide useful information regarding the (a) quality of work and communication with the entity and OIG; (b) timeliness of work performed; and (c) estimated costs?
Independence and Objectivity: Can the proposed IRO attest, in writing, that they meet the General Accepted Government Accountability Standards (GAGAS) as well as conflict of interest, independence and objectivity standards? Meeting GAGAS standards is an OIG requirement.