Medical Review Solutions for Group Health Plans

Since the Affordable Care Act (ACA) was enacted 10 years ago, there have been a flurry of changes within the healthcare industry. The law expanded coverage in the United States, especially through Medicaid, precipitated the transition from fee-for-service to value-based care and stimulated the move of medical records from paper-based to digital.  

Because the ACA was designed to improve care and reduce costs, the independent review industry experienced marked growth soon after the legislation was passed. The primary objectives of independent review organizations (IROs) are to help ensure that any proposed medical treatment is consistent with State or federal guidelines, plan language and or evidenced based medicine. Substantiated benefits of independent review include patient protection, positive impact on health plan review processes and other health care management activities, and a reduction of costly litigation.  

Similarly, utilization management services have become more prominent. This is because they enable payers to manage the cost of healthcare benefits by assessing appropriateness using evidence-based guidelines before a service is provided. Evidence-based clinical decisions are important as they are utilized to enhance care management.  

Group Health Plan-specific services  

Due to their high level of expertise in the healthcare industry, IROs and utilization management providers are able to offer specialized medical review solutions for Group Health Plans (GHPs). As noted by the National Association of Independent Review Organizations (NAIRO), IROs render increased transparency for both payers and providers, decreased risk through proactive risk management and improved member satisfaction through unbiased, evidenced-based external determination. 

Utilization Review 

The process of utilization review aims to assist payers in improving coordination of care, verifying members receive high-quality, medically necessary care, and improving organizational oversight. It also helps to reduce fraud, waste and abuse- a crucial component considering the U.S. healthcare system wastes an estimated $765 billion annually. 

Utilization review often includes medical director services, panel reviews for complex cases, as well as fully- or partially-delegated pre-service, concurrent and post-service physician level reviews. It aids payers in more efficiently managing growing case volumes and performing initial reviews, appeals, grievances and reconsiderations.  

Peer Review  

One type of peer review consists of managing a doctor’s performance and ensuring his or her skills are held to the highest standards. Another is physician-level review of medical records utilized by health plan professionals to determine whether or not to uphold a denial of coverage for a specific claim. Overall, peer review was developed to improve the quality and safety of patient care, reduce an organization's malpractice liability and meet regulatory requirements. This includes accreditation, licensure and Medicare participation. 

Peer review companies have been found to have a positive influence on health plans’ internal review processes, such as accelerating time frames for review and bringing in more external specialists for reviews of complex cases. They possess the capabilities and resources to deliver quicker turnaround times, meet appropriate guidelines and recommendations (both state and federal), provide unbiased decisions, eliminate conflicts of interest and ensure that all parties are treated fairly through a resolution based solely on clinical documentation.  

Drug Utilization Review 

Leading providers of drug utilization review (DUR) programs deliver prospective, concurrent and retrospective reviews that allow payers to assess the necessity and safety of drugs and/or medication regimens. Prospective DUR (PDUR) is an evaluation of planned drug therapy prior to dispensing, while concurrent DUR (CDUR) is a real-time review of the course of treatment, monitoring drug therapies and patient outcomes. 

Contrastingly, retrospective DUR (RDUR) detects patterns in prescribing, dispensing or administering drugs. It also prevents recurrence of inappropriate medication use or abuse. This is based on current patterns of medication use, prospective standards and target interventions. In drug utilization review, clinicians review patients’ prescription and medication data (and/or OTC drugs) before, during or after dispensing to ensure appropriate decision-making and positive patient outcomes.  

AMR’s wide array of offerings  

As a URAC-accredited national provider of independent medical and utilization reviews, AMR offers a wide array of services to group health organizations including acting as a delegated entity within utilization management programs. Our expertise extends across multiple lines of business including commercial, self-insured and government-sponsored health plans.  

AMR also proffers specialty review for appeals at all levels, including those involving binding decisions subject to ACA guidelines. We also provide reviews specific to behavioral health, dental, spine, and many other specialized areas of service. Our broad nationwide physician network not only allows rapid scalability in response to seasonal volume increases, but also affords us the ability to be a versatile partner to tackle case work backlogs or employ our board-certified physicians to act as medical directors to address temporary organizational changes or staffing shortages.  

The AMR difference  

As our vice president of strategic partnerships, Amanda Marfise Markle, explains, “AMR is one of the first national IROs and was founded by physicians who sought to improve the state of healthcare. From our infancy, we have placed importance on clinical quality, customer service and technology. This is ingrained in our employees and is the basis for our mission statement, ‘we believe every patient deserves quality healthcare.’”  

The AMR platform is consistently updated by our in-house technology development team to provide a user-friendly, intuitive and most-customizable referral and reporting system in the market. Our customizable technology enables our clients to meet their customers’ specific needs and focus on their business outcomes. In addition, our client management team has an average tenure of more than seven years with the company. Each staff member is very experienced in establishing various account types and meeting and exceeding the needs and requirements of each.  

Contact us to learn more about how our physician and allied health reviewers can assist your group health plan with decision-making for UM and appeals departments, provider quality, SIU, financial integrity and other needs.