Why I Don’t Believe it’s Patient vs. Payer

The second blog in a series from AMR’s management leadership – “Insights from the Inside” – in which Megan Kaufman, General Manager of AMR, shares her insights on the patient-payer relationship.

Too often, claims and appeals processes are portrayed in a way that pits Payers against Patients in the battle for patient wellness and quality healthcare. The system isn’t perfect, but there is little in life that truly is. I believe that the best way forward is to refine what works, analyze what doesn’t, and try new solutions with the intent and goal to continually improve the process over time. One way to help neutralize the “us vs them” mentality is to get everyone on the same side, with the same goal ahead, utilizing a resource outside the system. Advanced Medical Reviews (AMR), as a URAC accredited independent review organization (IRO), is in a unique position to be able to provide independent claims and appeals recommendations utilizing one of the nation’s largest physician peer review networks, encased in a culture where we believe quality healthcare is the ultimate goal.

 

IROs and Evidence-based medicine

As an IRO, our role is to facilitate treatment recommendations by way of our network of independent physician reviewers who provide these recommendations utilizing evidence-based medicine in their decision-making process. Using the most scientifically-sound information available, relevant guidelines and plan language, our reviews help get all parties on the same page about the most appropriate care that a patient should receive given his or her specific clinical situation. Payment for the service is not a factor; recommendations are based on the clinical information at hand and findings from the broader scientific community. Utilizing an IRO in the claims and appeals process provides an opportunity to remove bias and emotionally charged factors from decision-making. It results in an outcome that all parties can see is based on the best known information the clinical and scientific community has to offer, rather than a perception that the process is inherently biased.

 

Leveraging the physician reviewer network

AMR has one of the nation’s largest physician peer review networks. When it comes to making decisions in the claims and appeals process, patients and providers want to feel confident that decisions are being made by specialists that are familiar with the service or treatment under review, and that would be able to correctly interpret the intricacies of the patient’s medical situation. Through our robust network of over 1000 physicians and healthcare professionals, with specialists and sub-specialists available from across the country, we can help ensure that claims and appeals recommendations are made by the most knowledgeable practitioners for each particular patient.

 

Our shared goal: Making a difference

Having worked in healthcare for the past 15 years, I have met countless individuals across many different roles and jobs that tell me that they got into this industry because they genuinely care for people. They want to contribute to the wellness of others. They want to make a difference in someone’s quality of life. That’s why I’ve stuck around this long! The more people I meet, the more I see that we are all working toward a similar goal. Despite competing factors or differences of opinions, most individuals and most organizations in healthcare continually work toward providing all patients with quality healthcare. As an organization, AMR believes that every patient should receive quality healthcare. We live out that philosophy with every case and with every partnership.

The healthcare industry will continue to change and evolve and improve. I’m proud to be a part of the ongoing evolution and I’ll be looking for ways that we can contribute to ensuring that every patient receives quality healthcare. I look forward to partnering with individuals and organizations who are headed that way, too!

 

Connect with and follow Megan on LinkedIn to read more articles and stay up-to-date with company news!