The Affordable Care Act (ACA) was enacted in 2010 with three primary goals. First, to make affordable health insurance available to more people; second, to expand the Medicaid program to cover all adults with income below 138% of the federal poverty level; and third, to support innovative medical care delivery methods designed to lower the costs of health care generally. Also included in this legislation was the right of health plan members to request an independent medical review (IMR).
Typically, IMRs are utilized to establish the medical necessity or experimental and/or investigational status of treatments and evaluate other issues impacting the appropriateness of medical care. They are implemented by many private and government-sponsored health insurance programs. Performed by independent review organizations (IROs), IMRs ensure medical decisions are based on evidence-based medicine, current and relevant clinical research, regulatory requirements and practice guidelines based on the standard of care.
Unlike independent medical examinations (IMEs), which focus on diagnosis, appropriateness of care, causality and future treatment needs, IMRs do not involve an in-person examination of the patient. Both, however, are designed to be conducted by unbiased, actively practicing, Board-certified physicians with extensive and specialized medical knowledge.
A positive impact for patients and payers
We’ve highlighted in previous blogs some of the advantages of independent medical reviews, such as their positive influence on health plans’ internal review processes, including improved time frames for review, and bringing in more external specialists for reviews of complex cases.
There are other advantages that can be achieved by employing the services of a reliable IRO. According to the National Association of Independent Review Organizations (NAIRO), companies who utilize an IRO typically experience the following benefits:
- Reduced liability through the utilization of external, Board-certified specialists in the same or similar field of service as the original provider(s).
- Reduced liability through the development of standardized medical criteria for prior authorization.
- Improved member satisfaction through provision of an unbiased, evidenced-based external determination.
- Ensured compliance with DOL/ERISA compliance guidelines.
- Ensured compliance with state and federal mandates for appeals and medical necessity-based reviews.
Other substantiated benefits of independent reviews include patient protection and a positive impact on health plan review processes, and other health care management activities. By employing an IRO with proven experience in IMRs, the number of not medically necessary or inappropriate services and procedures can be reduced, helping to address fraud, waste and abuse in a health care industry that already has an excessively high rate of spending.
Advanced Medical Reviews: Leading the way in IMR and beyond
IROs utilize evidence-based reporting, along with clinical research, regulatory requirements and practice guidelines, to support their unbiased decision-making. They tailor the review process to meet the needs of each client to ensure the highest quality assurance and clinical accuracy.
Since 2004, Advanced Medical Reviews has been trusted to offer unbiased, accurate and high-quality IMR services based on evidence-based medicine. Because we provide decisions about medical care based solely on medical evidence, we’re able to serve as a reliable, objective resource with an extensive and specialized knowledge of health care services.
By setting the industry standard in providing quality IMR services that are timely, clinically accurate and efficient, we’re able to adhere to strict compliance requirements, deliver quick turnaround times, and meet the appropriate state and federal guidelines and recommendations.
Our skilled team is committed to our clients and their patients, and we focus on continuous quality improvement, innovation and client satisfaction. We implement advanced technology resources, such as our AMR Client Portal, to provide a highly customizable platform to fit our clients’ needs and promote operational efficiency.
At AMR, we know that IMRs benefit the health care industry overall, not only our clients, by improving productivity, increasing patient safety and further securing the rights of patients. IMRs also promote consumer rights, provide another resource for medical expertise and knowledge, and produce more effective claim management and better allocation of staff resources.
Since 2005, we have been fully accredited by URAC, a non-profit organization that helps promote health care quality through the accreditation of organizations involved in medical care services, in comprehensive internal and external independent reviews. AMR is also one of only a handful of IROs to have been accredited by the National Committee for Quality Assurance (NCQA), which serves as further evidence to our commitment to delivering the quality health care patients deserve. Contact us to learn more about our IMR services, and how we can help you achieve unparalleled results today!
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