Tech Solutions Rapidly Emerging for Review Orgs, With Potential for Big Returns

Technology solutions are fast-emerging in the clinical peer review space, from workflow tools that can streamline the medical review process to systems like natural language processing and machine learning that can unleash layers of efficiency.

While artificial intelligence-fueled technology, such as ChatGPT and Microsoft’s Bing chatbot, has grabbed headlines in recent weeks, it’s fair to wonder if AI is entering the medical claims review arena. Although it may be a tantalizing thought, experts say it’s not quite there yet.

“For our industry, I would say AI remains in the future,” says Ed Bolton, CEO and president of ProPeer Resources, a URAC-accredited independent review organization (IRO) based in Schertz, Texas, and immediate past president of the National Association of Independent Review Organizations (NAIRO).

Bolton is bullish on natural language processing, or NLP, as a solution that is “closest to having applicability” for medical claims review and utilization review organizations. Considered a branch of AI, NLP “enables computers to process human language in the form of text or voice data,” according to IBM, and that allows computer programs to “translate text from one language to another, respond to spoken commands, and summarize large volumes of text rapidly – even in real time.”

Because review organizations work with mountains of data, the potential benefits of an NLP program for medical review are highly significant. On March 29, NAIRO is hosting the 2023 Virtual Symposium on “The Use of Technology in the Review Process,” and the expert speakers are covering an array of tech-focused sessions, including those on NLP, machine learning and AI.

Organizations Must Vet Partners, Avoid Risks

Overall, the decision to invest in technology solutions can reap dividends for review organizations, but Bolton cautions that organizations need to have an understanding of the systems they’re investing in and how those systems can deliver a return on investment. “When a company is in the process of evaluating software, you have to have a baseline knowledge, and you have to know how it fits in your workflow,” he says.

For Mark Finger, M.D., medical director with the Empire State Medical, Scientific & Educational Foundation, a URAC-accredited independent review organization in New York, one area that would be helpful is a tool that can match clinical criteria to a particular case under review. Finger says that often there are different criteria at play because a hospital may submit one set while an insurance provider will submit another. An automated system that settles on a single criterion could cut out a lot of back and forth, saving time and resources.

Like any investment in technology, cybersecurity risks are of high concern, and that demands careful vetting of third-party partners to ensure they’re equipped to protect patient information. Working with vendors also raises some questions about securing contracts, Bolton says. “The fact that there is interdependency on third-party software could be a factor in eliminating a contract,” he says. Ultimately, “you have an obligation to do a risk assessment on the software you’re using,” Bolton adds.

When seeking a partner, organizations must be prepared to weigh “the tradeoff in terms of cost and complexity,” says Seth Lewin, M.D., with MedReview, a NAIRO member, and chair of NAIRO’s Accreditation Task Force. Lewin sees a clear need for technology-driven solutions, such as clinically validating DRGs and other areas.

Many small to mid-sized independent review organizations don’t have much in-house technology support, Bolton says, and that can lead to gaps in general knowhow. “Technology and cybersecurity knowledge varies widely among IROs,” he says.

As more solutions come to market, it is vital that IROs take a broad look at the available tools, how they will fit within their organizational workflow and ensure their partners provide reliable, up-to-date security measures to protect the ever-present swirl of data.

To learn more about the 2023 NAIRO Virtual Symposium on March 29, visit the overview page here:


NAIRO is an association of URAC-accredited IROs collaborating on issues facing the rapidly changing healthcare and workers’ compensation arena. NAIRO leadership and its member-driven committees track legislative and regulatory developments at the federal and state level, advances in accreditation standards, and emerging themes such as cybersecurity, trust, compliance, and more.

NAIRO is presenting a virtual symposium, "Technology in the Review Process," on March 29, 2023, from 12:30-4pm EST. Learn more about NAIRO here, and stay tuned to NAIRO’s events calendar for upcoming learning sessions.

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