Clinical Review Services for Medicare

Redefining Business as Usual in a Shifting Healthcare Landscape

In the wake of the COVID-19 pandemic, payer organizations face unprecedented levels of change and uncertainty. Member demographics are shifting, covered services are expanding, and demand is fluctuating—all to degrees unimaginable just six months ago. While all are impacted, those who provide Medicare and Medicaid services are feeling these ripple effects particularly acutely. Payers across the board are moving quickly to respond, while also looking ahead, thinking deeply about the future and what “business as usual” should look like as all adjust to a new normal. Many are turning to health utilization management (HUM) and independent review organizations (IRO), like AllMed, for support. HUM/IROs provide flexible capacity and on-demand expertise to help payers optimize existing resources and scale as caseload volume fluctuates.

Several months into this pandemic, with unemployment rates high, many payers are expecting a significant shift in member demographics from a drop in commercial coverage and an increase in Medicaid and Affordable Care Act enrollment.1 Recent state data indicates that the migration has begun—at least eleven states showed notable increases in Medicaid enrollment by the end of April, and three states that have posted data from May show even larger increases.2 The length of time it will take for this shift to happen, and its ultimate impact from state to state are unknown. What is clear is that the effects will be long-lasting and profound. As recently as June 10th, Federal Reserve officials projected high unemployment for several years to come and an arduous journey back from the pandemic-induced recession.3

Factors Driving Changing Landscape

At the same time, other variables also are moving, compounding uncertainty in the industry. Medicare’s recent expansion of coverage to include telehealth services combined with a population-wide increase in the use of telemedicine during the pandemic has the potential to change patterns of engagement on a large scale. Research indicates that once someone has tried telehealth services, they generally start to prefer them over many traditional in-person services.4 In addition, the restart of elective procedures such as hip and knee surgeries, deferred during the early months of the pandemic, is creating the prospect of a surge in Medicare claims.5 And as the strain of virus-related isolation and stress continues, calls to mental health lines are increasing, a trend that likely signals an upcoming uptick in behavioral health claims.6

While working hard to meet today’s challenges and maintain high-quality standards, payers are also planning for the future, reprioritizing operations to be better prepared for the uncertainty ahead. As industry leaders reinvent business models, many see a strategic role for health utilization management and independent review organizations such as AllMed.

Clinical Review Services Tailored to Your Needs

With customized decision making and utilization management solutions and a deep understanding of government programs, AllMed is uniquely positioned to help. Our reviewers have expertise in using various criteria, from policies and guidelines to Local and National Coverage Determinations and Articles (LCD/LCA/NCD). We know how turnaround time (TAT) and compliance requirements can impact your business, and we prioritize them. Our quality management system and commitment to Lean principles ensure excellence from end to end, enabling you to serve your members better and faster, pass accreditation and compliance audits, and improve your Medicare star ratings. Partnering with AllMed ensures that you have the knowledge and capacity you need, freeing your team to focus on higher priority initiatives.

Our Medicare and Medicaid reviews run the gamut from prior authorizations to external appeals. Like all our customized services, they are guided by the highest quality standards and designed to meet your specific and changing needs.

Clinical Review Services for Medicare and Medicaid

Our nurse and physician prior authorization review process, spanning prospective, concurrent and retrospective reviews, begins with a registered nurse. Reviews that cannot be nurse approved are forwarded to a physician for further consideration, reducing the potential need for costly appeals or additional medical treatment if medical care is delayed. Partnering with AllMed on prior authorizations enables you to augment your internal capabilities so that you can scale quickly and efficiently to meet changing demand.

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.

Summary of AllMed’s Clinical Review Services

  • Prospective, concurrent and retrospective reviews by registered nurses or physicians
  • Augment internal capabilities to scale quickly and efficiently
  • Evidence-base determinations from highly qualified specialists for complex cases
  • Minimize downstream appeals costs
  • First and second-level reviews by board-certified specialists
  • Improve quality and reduce costs
  • Comprehensive reviews that follow federal and state regulations
  • Meet compliance requirements with management through our in-house quality and compliance programs

Your Resource for Unbiased Defensible Determinations

Though prior authorization reviews and appeals are critical functions in healthcare payer organizations, they can be outsourced to a HUM/IRO, like AllMed, easily and securely, while ensuring high quality and compliance. By focusing on providing medical review services, AllMed optimizes cost and streamlines workflows and the process of nurse and physician recruiting and credentialing. Whether there is a barrage of incoming cases, a pandemic-induced lull, or physician vacation, a HUM/IRO partner has the resources to properly allocate clinical staff to meet a variable workload.

As these tumultuous times prompt an in-depth reassessment of business models, many leading payers are seeing the value of partnering with a health utilization management and independent review organization. For more than 25 years, AllMed has provided unbiased, defensible determinations to a wide range of payers with diverse needs, ensuring that every patient receives the right care at the right time while eliminating overutilization.

For more information about how AllMed can help your organization ensure review quality and integrity while controlling costs and decreasing turnaround times, contact us today.