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Article #104: Managing Evidence-Based Self-Insurance Plans

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Instead of contracting with a traditional self-funded insurance managers are
health insurer to provide group health required, by ERISA and state laws, to
insurance, many organizations are turning have questionable cases reviewed by
to self-funded insurance plans that are non-biased specialists within specific
managed by third-party administrators or timeframes.
an outside health management company. The primary issue here is how do the
According to the Employee Benefit management companies, without a full
Research Institute (EBRI), about 50 medical panel on staff, decide that
million workers are covered with treatment decisions are based on proven
self-insured group health plans. To help medical evidence each and every time? How
reduce costs and errors associated with do these companies ensure that they are
these plans, many of these entities are staying up-to-date with the latest
now evolving into "evidence-based" medically approved treatment options?
self-insurance plans. While some cases are obvious, partnering
Because self-insured plans are subject to with an Independent Review Organization
the Employee Retirement Income Security (IRO), such as AllMed Healthcare
Act (ERISA)-the federal law that protects Management, may be just the answer to
employees' retirement income and this issue. An IRO can provide access to
benefits-the same rights that are the broadest panel of specialists that
available to insureds with traditional can make sure decisions are based on
healthcare plans are available to proven medical evidence. And, an IRO can
individuals on a self-insured corporate also help guarantee state and federal
plan. This means that when treatments are deadlines are met by turning around
denied, for whatever reason, the patient review decisions within 48 hours or less.
has a right to appeal the decision and For more information on how an IRO can
have it reviewed by a like specialist not help your organization, please contact
involved in the original claims decision. AllMed at 800-400-9916.
When such a dispute arises, TPAs and






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