The Challenge

The Capital BlueCross Clinical Management department’s 140 employees process more than 6,800 insurance claims and pre-authorizations every month.  Throughout this process, maintaining quality and ensuring patients receive the best possible care are extremely important.  To ensure internal, state and federal guidelines are followed, Capital BlueCross has established an internal review team of nurses and physicians to help quickly assess and approve or deny questionable cases.

In addition, Capital BlueCross has just recently established an internal audit group to help flag questionable claims.  According to senior clinical product support consultant, Lynda Farner, Capital BlueCross uses this level of peer review primarily as a means to help detect either fraudulent billing or the overuse of certain procedures, such as lab tests.

The Solution

Capital BlueCross selected AllMed Healthcare Management, a leading Independent Review Organization (IRO) with more than 400 specialist peer reviewers, to help independently scrutinize its complex and questionable cases.

“AllMed provides us with access to the specialists we need for making decisions quickly and efficiently.”

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