In a study conducted by The Journal of Healthcare Information Management, it was discovered that 86 percent of mistakes made in the healthcare industry are administrative. These small administrative mistakes, whether it’s the misspelling of a name or a misrecorded number, can have a major effect when they go unnoticed. With the fast-paced and, at times, understaffed atmosphere of the medical field, it’s no wonder why these mistakes happen. In most cases, mistakes can be eliminated by fact-checking, communicating with the involved parties and conducting peer reviews.
This brings us to the medical review process, which involves taking time to evaluate the findings in a medical case. Physicians conduct a peer review during case evaluations, which means professionally reviewing the treating provider’s work or proposed work to determine an appeal on the case. A reviewer’s assignment is to consider evidence-based medical guidelines, health plan language, and state and federal regulations, as well as the specific clinical situation of the patient to determine whether or not the care given or proposed by the provider was appropriate and medically necessary.
Many insurance providers outsource their peer review process to independent review organizations (IROs). These cases must be reviewed by board-certified physicians of the same or similar specialty and certifications of the original treating provider. This evidence-based approach, performed by IROs, can uncover unnecessary treatment while enhancing the quality and effectiveness of patient care.
Making a Match
IROs use physicians with varying backgrounds and disciplines, bringing a variety of knowledge to the table. Matching the most applicable board-certified physicians to the right cases ensures peer reviews are managed with the highest level of knowledge and expertise while using widely-accepted criteria. Peer reviews done by a reputable, certified and nationally-accredited IRO gives clients access to a reviewer network comprised of practicing physicians across a wide range of specialties and subspecialties.
Along with this network of physicians, IROs conduct peer-to-peer calls to evaluate medical cases. With peer-to-peer calls, a reviewing physician communicates with the original providing physician to clarify findings and gain a better understanding of a case. When the reviewer has all the proper details and knowledge, he or she will reach the most-informed decision.
In addition to being able to strategically match the right physician to the right peer review, IROs are able to adhere to strict compliance requirements, deliver quick turnaround times, and offer transparency. For both payers and providers, IROs ensure only services which meet current clinical guidelines, adhere to state and federal regulations, and are deemed to be appropriate and medically necessary.
Access with AMR
At Advanced Medical Reviews, we conduct utilization management reviews and medical case reviews to offer our clients comprehensive and unbiased peer review services. AMR’s strong network of physician reviewers is just one of the reasons why we are one of the country’s top independent review organizations. As our recruitment and credentialing manager, Leah Williams, attests, “AMR and the physician reviewers we partner with are given an opportunity to positively contribute to the quality of patient care with every claim. Making sure that the physicians in our network not only ascribe to the belief that every patient deserves quality care but are also willing to contribute to the ever-improving standards of care is paramount to our mission.”
Our ability to expertly match the right physician to review the right medical case is integrated with our AMR Client Portal. A flexible and intuitive platform that utilizes the most up-to-date and evidence-based medical research and guidelines, it enables a seamless review process through fully-customized templates, easy trackability of in-process reviews and a powerful search function for data analysis. Customizable to your workflows and needs, the platform is one of the most secure in the industry.