Independent Review Organization Services

Health care organizations are often required to select an Independent Review Organization (IRO) as part of their compliance obligations under a Corporate Integrity Agreement (CIA). Strategic Management provides health care IRO services, including conducting reviews of claims, arrangements, transaction, unallowable costs, marketing practice and compliance. Strategic Management also conducts mock IRO reviews to help prepare health care organizations in meeting their CIA obligations.

Arrangements Reviews

Strategic Management consultants conduct reviews of arrangements between the health care organization and its practitioners, suppliers, vendors and other health care providers. As an IRO, we determine if the arrangement complies with the Anti-Kickback Statute, the Stark Law and CIA requirements. Arrangements reviews are conducted by health care consultants with legal training and who are experts in reviewing transactions under the statutory and regulatory standards governing such arrangements.

Claims Reviews

Cornelia Dorfschmid, Ph.D., leads a team of certified auditors, coders, medical professionals, statistician and compliance consultants to conduct claims reviews in accordance with CIA requirements. Our team has the expertise to develop a sampling strategy in accordance with the OIG’s approved RAT-STATS methodology and generally accepted statistical practices.  

Systems Review

Strategic Management consultants conduct reviews of the health care organization’s systems, including processes, policies, and procedures, that track, monitor and verify claims, arrangements, pricing and marketing and sales activities. Our consultants have specialized knowledge and experience with the types of systems to be reviewed, as well as the governing Federal requirements and standards.

Transaction Reviews

Strategic Management has the statistics expertise to select the sample(s) of transactions to be reviewed in accordance with OIG RAT-STATS and CMS Program Integrity standards. Transaction reviews are conducted by a team lead by Cornelia Dorfschmid, Ph.D., with expertise on the issues being reviewed, e.g. compliance with the Anti-Kickback Statute, Stark Law, CMS program coverage, claims and reimbursement.

Unallowable Costs Reviews

Steve Forman, CPA, leads a team with financial expertise to conduct financial audits and make determinations on unallowable costs. Strategic Management consultants conduct a review of unallowable costs included in a health care organization’s cost reports or claims submitted to Federal health care programs. We determine if unallowable costs were reported and adjusted and are not included on the future cost report or claims.

Marketing Practices Reviews

Rita Isnar, JD, leads a team of consultants to examine marketing practices carried out by pharmaceutical or device manufacturers, managed care organizations and other types of health care organizations. Our consultants have professional training and expertise to conduct marketing reviews and to determine whether marketing practices are conducted in accordance with Federal requirements and standards.

Secret Shopping & Compliance Reviews

Strategic Management consultants monitor marketing practices of pharmaceutical and device manufacturers and marketing and enrollment practices of managed care organizations. We conduct secret shops by posing as a Medicare or Medicaid eligible beneficiary seeking information about or enrollment in the organization and determine whether the organization conducts its marketing or enrollment practices in accordance with Federal requirements.