AllMed Healthcare Independent Medical Reviews - Q-elements Independent Medical Review Case Study
How AllMed Healthcare's independent medical reviews helped Q-elements ensure contract guideline compliance and medical necessity on its processed medical pre-authorizations.
(PRWEB) December 9, 2004 -- How AllMed Healthcare's independent medical
reviews helped Q-elements ensure contract guideline compliance and medical
necessity on its processed medical pre-authorizations.
About
Q-elements
Q-elements (http://www.qelements.com), formerly a part of HealthSmart®
Preferred Care, provides comprehensive managed care solutions, including
utilization management, case management, disease management, wellness
programming and quality/compliance support for more than 150,000 insures located
in over 28 states throughout the U.S. An experienced staff of more than 20 case
managers, medical professionals and administrators process more than 3,000
monthly pre-authorizations per month.
The Challenge
Of the more than
3,000 pre-authorizations processed per month, about 1 percent, or 25 to 30,
requires further review to ensure they are in compliance with contract
guidelines or are medically necessary. Maintaining a quality and timely process
to ensure patients receive the care they need and are entitled throughout this
process is extremely important. Q-elements also requires a review process that
ensures decisions on questionable cases are made within state-mandated deadlines
and completed by like physicians or specialists.
Q-elements does not
maintain a full panel of specialists internally, so the company must turn to
outside physicians, or peers, for external independent medical reviews. The
types of cases typically sent for external independent medical review are either
deemed experimental in nature or identified as not meeting the initial criteria
for coverage. These independent medical reviews must be completed by an
external, third-party independent review organization (IRO), preferably not in
the same community, to ensure the decisions are unbiased and based on proven
medical facts and evidence.
The Solution
Q-elements has turned to
Portland-based AllMed Healthcare Management, a leading independent review
organization (IRO) with more than 200 specialist peer reviewers, to help
independently scrutinize its complex and questionable cases.
“AllMed
provides us with access to the specialists we need for making decisions quickly
and efficiently,” said Tanya McAfee, vice president of Care Management at
Q-elements. “The doctors are very responsive, easy to talk with and make
themselves available to speak to our medical director, and even the treating
physicians, when the provider does not agree with the decision. AllMed’s
dedication to customer service and responsiveness has helped us meet the
requirements established by the state and better serve our customers.”
The Outcome
The addition of AllMed as an Independent Review
Organization has enabled Q-elements to improve its independent medical review
process, gain access to specialists, make it easier to meet required
state-mandated response times and reduce further appeals. The majority of the
cases reviewed by AllMed are finalized within 48 hours or less, with many being
completed the same day in as little as an hour of being
received.
Because AllMed recommendations are
based upon medical evidence, the company is able provide defensible decisions
that are seldom questioned further. The staff also works closely with the
third-party administrator’s nurses and medical staff throughout the
decision-making and review process. McAfee adds that one of AllMed’s biggest
strengths is the staff’s adaptability and flexibility. “Whether new information
becomes available or a patient or doctor simply has a question, AllMed’s doctors
always make themselves available throughout the medical review
process.”
About AllMed Healthcare Management
Founded in 1995, AllMed
is a URAC-accredited Independent Review Organization (IRO) serving insurers,
healthcare providers and third-party administrators throughout the United
States. Independent medical reviews are conducted by a panel of working
physicians and specialists. More information on AllMed can be found on the
company’s Web site at http://www.allmedmd.com.
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Source : http://www.prweb.com/releases/2004/12/prweb186413.htm