Independent Medical Reviews
April 20, 2015
Since the passage of the Affordable Care Act, health care and group health plans have undergone major transformations. More than ever, insurance companies are focused on ensuring the highest quality care, and they are partnering with IROs to help them deliver that care.
At Advanced Medical Reviews, we offer three basic types of reviews: medical case reviews, pharmacy benefit reviews, and utilization management reviews. But are you aware of the many special project types we offer, as well? We also offer direct physician consulting, dispute resolution, panel reviews, audits, and much more.
Let's address a major reason why group health plans turn to IROs for IMRs: time. Health care plans and hospitals need as much time as possible to devote to quality healthcare, and partnering with IROs for case reviews gives them that time. IROs are excellent partners for case review because they expedite the review process with efficient web portals, give access to physicians with a diverse set of specialties, and, especially here at AMR, are able to think "outside the box" and complete special project work.
The five most common types of reviews, but certainly not the only types of reviews, used by group health plans include: medical necessity reviews, peer-to-peer reviews, guideline reviews, 1st through 3rd level appeals, and length of stay reviews.
Medical necessity reviews can generate from any department, with examples ranging from investigations into fraud, DME and unbundling of codes. In peer-to-peer reviews, physician reviewers are not only looking for unfair billing practices, but they are also examining the healthcare provider's choices to ensure that the patient received the highest quality care. Physicians today are managing much more than simply caring for patients, and sometimes they don't have the required time to assess whether a course of care is still effective. This is another reason why partnering with IROs can make a difference- so physicians can spend more time with their patients.
Guideline reviews interpret the plan language to determine its unique coverage. Reviewers also assess whether or not the insurance plan is up to date with the latest medical research and evidence. 1st through 3rd level appeals and length of stay reviews are common reviews generated from the appeals and grievance department. The bottom line for all of these reviews is whether or not the patient received the highest quality level of care that they needed.
There are many other types of reviews IROs can provide, and as the health care system continues to evolve, the need for IROs will evolve, as well. We encourage you to consider partnering with Advanced Medical Reviews for both your most common reviews and any special project work that requires creative thinking and unique resources. The driving force behind Advanced Medical Reviews' approach to independent medical reviews is summed up in our philosophy- "We believe every patient should receive quality health care."
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