OIG Issues Updated IRO Independence and Objectivity Criteria.

The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently updated its guidance for assessing Independent Review Organizations (IROs).  Health care providers under a Corporate Integrity Agreement (CIA) engage IROs to review cost reports, physician arrangements, and claims, among other areas.  The CIA requires the IRO to certify that it conducts the review with independence and objectivity.  The OIG previously issued guidance on (1) factors affecting IRO independence and objectivity; and (2) the types of IRO reviews included in CIAs.  The most recent guidance contains the 2011 updates to the Government Accountability Office (GAO) auditing standards and presents examples of circumstances potentially affecting IRO independence.

The OIG considers the following GAO auditing standards to assess IRO independence and objectivity:

• The staff assigned to perform the review must possess the technical knowledge, skills, and experience necessary to perform the specific type of CIA review for which the IRO is retained;
• Objectivity includes impartiality, intellectual honesty, and freedom from conflicts of interest;
• The IRO must exhibit independence of mind and independence in appearance to ensure that any opinions, findings, conclusions, judgments, and recommendations are impartial; and
• Whether a particular threat has impaired IRO independence depends on:
  • The nature of the threat;
  • The ability of the threat to compromise or appear to compromise professional judgment; and
  • The specific safeguards applied to eliminate or reduce the threat.

Further, the OIG provided examples of services that likely would not impair IRO independence and objectivity, including:

• Conducting general compliance training on the provider’s CIA requirements and overall compliance program;
• Completing routine tasks surrounding the provider’s confidential disclosure program;
• Screening the provider’s employees against the federal and state exclusion databases; and
• Performing work plan procedures developed by the provider’s internal audit department that are unrelated to the subject matter of the CIA reviews.

Additionally, the OIG provided examples of services that likely would impair IRO independence and objectivity, including:

• Using a billing system or coding software developed by the IRO when the IRO is engaged to perform a claims review;
• Providing specific training addressing the subject matter of the CIA review;
• Developing the provider’s policies, procedures, or internal controls systems; and
• Participating in decision making related to the provider’s confidential disclosure program.

The OIG guidance is available at:

https://oig.hhs.gov/fraud/cia/docs/iro-guidance-2016.pdf.

Department of Health and Human Services Office of Inspector General.  “OIG Guidance on IRO Independence and Objectivity.”  Guidance Document.  22 Aug. 2016.