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Independent, External Medical Review Services

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Member Grievances & Appeals

Appeals Departments within payer organizations of all types turn to AllMed to review the medical necessity of claims that have been denied coverage and are being appealed by the member.  This fulfills state external review requirements, as well as federal ERISA and Department of Labor regulations that require an independent review by a specialist with the appropriate credentials.  While compliance is a key driver for employing IROs to review appeals, leading health plans gain the benefit of transparency and objectivity that instills confidence in their members and groups.

Preauthorization Reviews

Most complex and critical medical procedures are subject to pre-certification, and AllMed provides specialty match services that power payers’ medical management and utilization review workflows.  Organ transplants, oncology treatments, growth hormone therapy and bariatric surgery are just a few examples of the types of determinations we make for leading payers, every day.

Concurrent Review

Inpatient care management is a challenge to medical management organizations, and AllMed helps payers to better assess and manage appropriate service delivery to its members, while containing costs.  Making proper length of stay, level of care and discharge planning decisions increasingly demands the involvement of a medical specialist.  AllMed delivers concurrent review support to its clients, with the industry’s fastest turnaround times.

Provider Grievances & Appeals

As provider reimbursements and over-utilization continue to rise, health insurers are compelled to scrutinize provider billing practices.  AllMed helps payer organizations adjudicate provider appeals in an objective and consistent manner, by reviewing the medical necessity of complex treatments along with associated coding.  This helps major health plans that were party to the Thomas Love Settlement, as well as other payers that are interested in identifying and challenging questionable and costly reimbursements.  In many cases, the only way to make a fair, evidence-based determination is through medical specialty review.

Provider Quality of Care Reviews

In addition to scrutinizing provider billing to ensure fair reimbursement of services rendered, payers want to ensure their members are receiving the highest quality of care.  AllMed’s medical specialty review services help payers to determine whether a provider complies with clinical quality criteria for a specific procedure and that standard of care has been met.

Medicare & Medicaid Reviews

The advent of patient advocacy groups in the MEDICARE and MEDICAID segments has translated into higher member appeals and increased litigation.  Applying the latest medical evidence and CMS criteria to coverage determinations is increasingly difficult for payers, as standards of care continue to change.  That’s why payer organizations increasingly resort to external medical peer review by physician specialists from AllMed.   Health plans turn to AllMed to help them reduce or avoid expensive and lengthy ALJ appeal processes, by conducting up-front medical specialty reviews that lend objectivity and credibility to each case determination.  

Clinical Care Guideline Development

In the face of new technologies, drugs and clinical procedures, medical management organizations must develop new care paths for their case managers to use in guiding care for their members.  AllMed provides medical specialist expertise to help you develop or validate new case management guidelines.  By using specialists to peer review new care paths prior to deployment to your case managers, you can ensure your members receive state of the art care based on the latest clinical evidence, which is validated by top medical experts.

Medical Policy & Plan Language Reviews

Medical policy and plan language is in a state of continuous evolution, and medical specialist expertise is needed in order to apply the latest evidence to formulating these policies.  AllMed helps medical policy professionals to analyze determination outcomes data, and provide specialty match reviews which aid in the formulation and validation of medical policies.

Peer Review Panels

Many health plans use peer review panels to conduct hearings and review member and provider grievances and appeals.  AllMed’s in-house Medical Directors and Peer Specialty Reviewers regularly participate in these review proceedings, helping to ensure objectivity and fairness to all concerned parties.

Medical Director Services

Health plans, TPAs and other payers rely on AllMed’s in-house staff of physicians to act as their Medical Directors on an ongoing or temporary basis.  AllMed’s Medical Director Services allow payer organizations to fulfill their obligations for clinical decision making and policy development, at a fraction of the cost of a full-time Medical Director.  Contact AllMed to discuss your fractional needs, or to fill in for staffing vacancies and vacations.

 

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