Physician reviewers

Beyond COVID-19: Payers Plan for a New Normal

The COVID-19 pandemic has brought unprecedented and ongoing disruption to our everyday lives and the U.S. health care system. Now, several months in, hope is surfacing that the urgency and scale of the crisis may serve as catalysts for positive, long-term change. Within health care, the pandemic is spurring innovation while reaffirming the importance of flexibility and collaboration in solving problems. Examples include providers quickly offering telehealth options in response to Centers for Medicare & Medicaid (CMS) policy changes; state governments adapting licensing requirements to allow providers to cross state lines to meet surging capacity demands; and health plans retraining nurses from utilization management to proactively call members to address their crisis-related needs.1

At AllMed, we have a long history of building flexible and collaborative solutions that help payers resolve resource allocation and utilization management problems. For over 25 years, we have partnered with payer organizations of all sizes, providing added capacity and timely, specialized expertise to help meet changing needs. With our extensive experience, we are uniquely qualified to support your organization as you retool for the changes ahead.  

Ripple Effects Redefining Health Care

The trends emerging from the current crisis will redefine health care for years to come. In the big picture, perhaps most significant is the pandemic’s impact on employment. While the full extent is not yet known, it is clear that as large numbers of people lose their jobs, the percentage of the population that will be covered by health insurance will vary significantly. For many, coverage may change a few times over a 12-month period, switching from employer-based coverage to Medicaid and, potentially, back again.2  Ongoing demographic shifts will make planning for the future more challenging than ever for payers—particularly those who provide Medicare and Medicaid services.

Already, a coming surge is forecasted for services covered by Medicaid, as high unemployment drives continuing increases in the program’s enrollment. Medicaid is the largest payer for behavioral health services in the U.S.3  As demands for behavioral health services rise, payers who provide Medicaid services may find it difficult to recruit enough behavioral health specialists to review claims promptly and meet patient needs.

Similarly, a significant uptick in elective surgeries—delayed while the stay-at-home orders were in place—is expected as restrictions ease. Payers who serve Medicare members may have difficulty finding specialists to review claims for hip, knee, and other orthopedic surgeries on a timely basis. Delays can cause complications in a population with comorbidities, raising the prospect of increased health care costs if the need is unmet.

As membership mixes become more fluid, methods of care delivery and regulations are changing as well. At the federal level, CMS’ waivers of certain restrictions on telemedicine delivery are fueling a dramatic increase in the use of telehealth and virtual care options. A recent report from Frost & Sullivan projects that telehealth’s uptake will increase by 64.3% nationwide this year, and a sevenfold increase is expected by 2025.4 This overwhelming response suggests that telehealth is on its way to becoming the new normal. In light of these and other changes, leading payers are reevaluating their business models, thinking about how best to continue to provide high-quality service and control utilization in a new, continually shifting environment. Many are turning to health utilization management (HUM) and independent review organizations (IRO), like AllMed, for on-demand expertise and flexible capacity.


Our Mission: To Support You as an Extension of Your Team

With our specialized knowledge and deep understanding of government programs and regulations, AllMed is ready to help. We work as an extension of your team to provide reviews that meet your high standards of quality with the timely turnarounds that you need. Partnering with AllMed can help you boost patient satisfaction, leading to improved Medicare star ratings.

We provide a wide range of services, including nurse-physician (generalist) reviews for prior authorizations. These first-level review services span prospective, concurrent, and retrospective reviews. The process begins with a registered nurse. Any reviews that cannot be nurse approved are forwarded to a physician for further consideration, reducing the need for costly appeals or additional treatment if medical care is delayed.

For complex cases, our customized, specialty-matched prior authorizations, delivered by highly qualified physician peer reviewers, provide you with detailed, defensible determinations. Using specialized experts at the beginning of the utilization management process fosters accurate, medically necessary approval or denial—reducing the need for downstream appeals.

Our appeals review solutions range from first and second-level internal reviews to state and federal external appeals. All reviews are conducted by board-certified specialists and sub-specialists who are in active practice. Each appeal review is performed in compliance with URAC, NCQA, CMS, state, and other federal regulations and is subject to oversight and audit through our Quality and Compliance programs.

Customized Clinical Decision Making for Medicare and Medicaid

Our Medicare Part D review services include prior authorizations, formulary exceptions, tier exceptions, and Medicare B versus D determinations.

We support payers who provide Medicaid and MedAdvantage services, drawing on the expertise of specialists in many fields and a robust panel of behavioral health and internal/family medicine providers. We have dedicated teams devoted to nursing and coding cases—each team has editorial capacities for state-compliant patient and provider communications.

In addition to providing review services and support, we draw on our policy and program expertise to assist you in passing accreditation and compliance audits.

AllMed’s wide variety of customized clinical decision making and utilization management solutions reflect our commitment to end-to-end quality and excellence. As caseloads fluctuate, you can rely on AllMed for expertise and resources to meet your changing needs and ensure compliance with industry and government requirements. For more information, contact us today.