The business world is full of acronyms. Terms such as ROI (return on investment), CMS (content management system), CPL (cost per lead), KPI (key performance indicator) and API (application program interface) are discussed by many working professionals on a regular basis.
Two well-known acronyms for health plans and payers are IME, otherwise known as independent medical examination, and IMR, or independent medical review. Though both terms are often used together because they serve a common purpose, they’re comprised of different steps and strategies. In this blog, we’ll define each term and provide advantages offered by each process.
Independent medical examinations typically are requested by self-insured employers and companies that deal with labor and industry. Conducted by medical providers, including Board-certified physicians, dentists or chiropractors, they involve a physical exam by an independent physician who also reviews the medical history of the case. The selected physician is one who has specialization in the case topic and has not previously been responsible for the care of the person on whom the examination is centered.
IMEs focus on diagnosis, appropriateness of care, causality and future treatment needs. Insurance companies and other third-party payers may request an IME to settle a disagreement about a course of medical treatment or examine claims for long-term disability, personal injury from an outside source or workers’ compensation. The goal of an IME in these instances is to prevent overutilization.
One primary advantage of IMEs for parties that request them is independent review by an unbiased, third-party source with extensive and specialized medical knowledge. The IME process also can help reduce insurance fraud, the cost of which, according to the FBI, is estimated to be more than $40 billion per year. Utilizing professional services in the independent medical examination process offers quicker settlement of disputed cases, a benefit for both health plans and payers, and the person involved in the dispute.
Independent Medical Reviews
IMRs are a right provided to health plan members as part of the Affordable Care Act (ACA) and are used to determine coverage of medical necessity, experimental and/or investigational treatments, preexisting conditions and other similar issues. Implemented by many private and government-sponsored health insurance companies, they ensure medical decisions are made according to evidence-based medical standards, clinical research, regulatory requirements and practice guidelines. Similar to IMEs, they are designed to be conducted by unbiased Board-certified physicians with extensive and specialized medical knowledge.
In addition to providing decisions about medical care based solely on medical evidence, IMRs are a cost-effective way to resolve disputes on medical benefit and payment, and aid in preventing unnecessary services. This helps reduce waste, especially in the healthcare industry, which in the United States has an increasingly high rate of spending. Like IMEs, IMR can be used as a fraud detection tool and for negotiations in liability claims.
According to a study by the American Association of Health Plans (AAHP), IMRs have a positive influence on health plans’ internal review processes, including accelerating time frames for review and bringing in more external specialists for reviews of complex cases. Other validated benefits of independent reviews include patient protection, cost-effectiveness, positive impact on health plan review processes and other healthcare management activities and reduction of costly litigation. Used in combination with IMEs, IMRs offer a comprehensive, knowledge-based resource for numerous health plans and payers.
View a demo of the AMR client portal to see how Advanced Medical Reviews can assist your organization’s operations with quick processing, data mining and specialized reporting in your independent medical reviews.