Some of America's largest health plans still turn to IROs for medical decision making and review of appeals. Why is this? Even though they have large numbers of physicians on staff, they can not afford to make the wrong medical decisions on all the claims they review. Also, medical staff at large health plans is consumed by other duties that often make it difficult for them to make speedy claims decisions. They also sometimes lack the specialty knowledge that is necessary to match an internal physician with the specific specialty involved in a claim. Finally, health plans struggle to find the right provider and the right specialist and get them to review a case quickly. Using an IRO is a lot easier.

So while many health plans have large staffs of physicians to look at appeals and decide claims, it still makes sense to have a relationship to an independent review organization to fill in the gaps in specialty knowledge and assure proper turnaround time.