Ero Administration Program

Managing three accredited IROs within the ACA’s external review appeal process can be a daunting task.  Let MCMC’s experts locate, vet, negotiate, audit, and provide reports as required by the Affordable Care Act. ACA requires all non-grandfathered health plans to engage a minimum of three quality accredited Independent Review Organizations (IROs) to manage the new external review appeal process.  Our External Review Administration program manages the appeal process and ensures full compliance with ACA.

MCMC External Review Administration Program Overview

  • Provides clients with significant ERO administration experience
  • Has compliance officer to ensure ACA compliance
  • Provides one point of contact and a dedicated ERO team
  • Contracts with a minimum of 3 quality accredited IROs
  • Assigns cases on rotational basis
  • Avoids “conflicts of interest”
  • Audits IROs for compliance
  • Recruits to replace non-performing IROs
  • Pays IRO
  • Maintains information
  • Provides annual reporting

For nearly 30 years MCMC has provided independent medical review to hundreds of health plans, managed care companies, employers, Taft-Hartley funds, TPAs, and government agencies.  MCMC was one of the first IROs to provide federal external review services and perform external review at the state level.

External Review Workflow

  • Receipt of review
  • Preliminary screen
  • Organizational “conflict of interest” check
  • Deem exhausted internal appeals
  • Initial notification to member
  • Request additional documentation
  • Review materials submitted
  • Submit additional information to plan for reconsideration
  • Quality assurance review
  • Assign case to reviewer
  • Final external review decision
  • Standard 45 days/expedited 72 hours
  • Determination to carrier & claimant/representative