Independent Review Organizations (IRO): A Necessary Evil

February 4, 2022

IRO

Providers who are lucky enough to have their fraud, waste, and abuse matters resolved through a civil settlement (either via the US Attorney’s Office or the Office of Counsel to the Inspector General-a CMPL action), can sometimes have a clause in the settlement that includes a Corporate Integrity Agreement (CIA) or Provider Integrity Agreement (PIA). 

Without going into the dreaded details, it is important to know that part of the CIA/PIA will usually include the use of an IRO.  IROs serve to oversee the CIA, and in particular, work to provide the yearly mandatory reporting that is needed to fulfill the requirements of the CIA/PIA.  Often times, companies and providers will be unhappy about having to bring an IRO into the mix, as there are obvious costs involved. 

It is, however, a necessary evil that is needed to ensure compliance with the terms of the CIA/PIA.  In the end, the IRO works to help the company or provider under the CIA, and hopefully sets that provider or company on a path to be successful in their future compliance and FWA efforts. 

As on OIG agent, I always wanted to make sure that the Medicare program was made “whole,” knowing that often times, the full amount of fraud that I believed to be the case was not being recovered.  That being said, if I had an investigation where I identified a loss to the program, I surely wanted $2 for every dollar stolen. 

In some instances I was unhappy that the matter was being handled as a civil case, when I thought it should be a criminal matter. In other instances, I was happy to offer my thoughts on why the issue was better resolved as a civil matter.  In either event, my number one concern was whether or not the Medicare Trust Fund was being made as “whole” as possible.  IROs and collaterally, those that work with an IRO to support the yearly reporting, are an integral part of that process. 

We at Advize have worked with IROs in the past, and I personally take great pleasure in doing that work.  To me, it is an extension of the work I did as an OIG agent; keeping those who have gone afoul on the straight path. 

My old mentor at the OIG had a lot of “isms” that he would spew in the course of a day.  One of my favorites that I have fully adopted was to tell people I was not a Federal Agent, but rather that I was “an anti-social behavior modification specialist.”  To this day, I hold that to be true.  It is more about how far off the path has the provider gone, and can it be salvaged.

By Eric Rubenstein

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