Clinical Reviewer FAQs

As a Clinical Reviewer, would I be considered an IPRO employee?

No. Clinical reviewers are independent contractors, executing distinct letters of agreement with IPRO. They receive payment on an hourly basis.

How many reviews can I expect to be assigned annually?

This depends on the volume of cases assigned to IPRO that fall within your specialty and cannot be predicted.

Where would I perform the reviews?

You may work from your office or home. Review assignments may be FedExed to you, depending on the requirements of the case. There is no physical examination of the patient.

How long will I generally have to conduct the review?
(For external review cases only)

This varies by contract, with the deadline ranging from 7 to 10 days. For an expedited case, where a delay may place the patient's health in jeopardy, 24 to 48 hour turnaround is typically required.

Will IPRO provide training?

Training is contract-specific and tailored to the needs of each Clinical Reviewer.

What if I have a question?

Two highly experienced Medical Directors are assigned to support IPRO's Clinical Reviewers and are available by telephone and E-mail.

What if I need more information on a particular case?
(For external review cases only)

All requests for additional information needed from the provider, insurer or insured must be channeled through IPRO. Each case is screened to ensure the file is complete prior to being assigned to a Clinical Reviewer, so the need for additional information is atypical.

What information sources would I use to render a final determination?
(For external review cases only)

Again, this depends somewhat on the contract. The following are typical inputs to the decision making process:

all relevant clinical information provided relating to the enrollee's physical and mental condition, such as pertinent medical records, consulting physician reports and information provided in the appeal request;
evidence-based medicine and provided in available literature, relevant clinical standards and guidelines, including practice guidelines developed by the Federal government, national, state or local medical societies, boards or associations; and Agency for Health Research and Quality guidelines;
state regulations;
provisions of the insured's health plan; and
your clinical judgment.

Is the Clinical Reviewer's decision final?
(For external review cases only)

All determinations are reviewed by a Medical Director and the Program Director to ensure that all appeal issues were addressed, the terms of the insured's contract regarding coverage were considered, and the decision is consistent with determinations rendered on other appeals that present the same or a substantially similar issue. If there is any question about a Clinical Reviewer's opinion, the Medical Director will contact the reviewer directly.