Medical Review Business Process Outsourcing Increasing Among Healthcare Payer Organizations

Portland, OR (PRWEB) June 22, 2012

Among health insurance entities, including health plans, medical management companies and third-party administrators (TPAs), a continuing objective is to reduce costs, improve quality, and meet rigorous accreditation and regulatory compliance standards. This challenge is especially true when it comes to reviewing the medical necessity of service requests, including pre-authorizations as well as member and provider appeals.

AllMed Healthcare Management’s recent webinar on physician review business process outsourcing (BPO) provided an excellent example of how payer organizations are increasingly turning to specialty BPO organizations like IROs and delegating medical decision making functions that used to be done by internal medical staff. In presenting this example of BPO innovation, AllMed cited several important reasons why health plans are moving in this direction. In particular, physician review business process outsourcing allows health plans to reduce costs, scale their resources up and down with variable volumes, and allocate their medical directors to higher value-added tasks.

“Health plan medical directors are often called upon to review pre-authorization and appeals requests, which reduces the time they can devote to the oversight of quality, compliance and clinical operations functions,” said Andrew G. Rowe, CEO of AllMed. “Given the compensation levels of these professionals, it makes more sense to outsource routine medical review tasks and redeploy medical directors where their higher-level expertise is of most value to the organization.”

Given this shift in thinking about how best to utilize internal medical staff, leading IROs have evolved and can now function as full service business process outsourcing partners for a health plan as it relates to medical decision making. High-performance IROs have developed an integrated portfolio of services that are delivered through web-based technology platforms. “The IRO can now reduce and/or balance workloads inside the health plan, lowering costs and improving productivity in ways not possible before,” Rowe added.

One such plan that recognizes this is Cambia Health Solutions, which operates BlueCross and/or BlueShield health plans in four western states, serving nearly 2.5 million members. The Regence affiliated companies have fully integrated their IRO (AllMed) into their clinical decision-making operations as a BPO partner. It relies on the company for outsourcing of all physician review functions, including first-level pre-authorizations and specialty-matched appeals.

“An outsourcing partner like AllMed is a really good fit for us,” said Csaba Mera, MD, Executive Medical Director of Regence BlueCross BlueShield of Oregon. “It has a large panel of physicians available for specialty-matched case reviews through a secure web portal, which improves our turnaround time on pre-authorizations and appeals. This gives our medical directors more freedom to focus on higher-level tasks – such as medical policy development, provider services support and implementation of required regulatory programs.”

But choosing the right IRO partner requires solid due-diligence, Mera would say, confirming that the partner needs to bring together all the cross-functional disciplines and expertise in physician recruiting, credentialing, training, quality assurance and compliance. Further, the full-service IRO should offer a solution that is highly optimized and integrated into the health plan’s clinical decision-making workflows. “In the end, such a solution must be faster, better, and cheaper than what a health plan can develop and maintain on its own,” he added.

Rowe outlined the technology capabilities and platform a payer should look for in looking for an IRO to partner with. These include:

•     IT security that ensures the IRO manages data at the same levels as its clients does. Among the technology capabilities to assure this are multi-factor authentication, data loss prevention systems, intrusion detection and rigorous audit controls, in addition to hosting of all systems at a data center which is subject to SAS-70 audits.
•     Reliability/availability features that ensure the IRO’s services will always be accessible when the payer’s clinical organization needs them. Among most important technology investments is redundancy at all levels, from switches to routers, to web and file servers. If one of these goes down, there is fast fail-over to a backup system.
•     Disaster recovery, where all systems are replicated to an alternate site or to the cloud. Thus if an IRO’s web portal goes down, an exact replica of the web application will come online within minutes.
•     A Quality Management System , including the ability to collect real time customer feedback, thus ensuring that all reviews are accurate and comply with customers’ requirements.

A growing number of health plans see BPO as a new model by which to engage with IROs, far beyond their traditional role of only providing reviews of external appeals. They realize that success in implementing it hinges on choosing an IRO partner which has made the necessary investments in technology, process development and quality management. Health plans that embrace BPO and choose an IRO partner wisely will find that they can serve their members more effectively and will earn stronger positions in the markets they serve.

About AllMed Healthcare Management
Founded in 1995, AllMed is a medical review outsourcing partner to leading health insurance payers, third-party administrators, medical management and claims organizations, nationwide. Its BPO services cover all levels and types of medical review services for payers. Services are delivered through PeerPoint®, AllMed’s state-of-the-art medical review portal. PeerPoint provides a secure, world-class technology platform that accommodates all health plan physician review processes. Reviews are conducted by AllMed’s team of more than 400 licensed, board-certified physician specialists who are in active practice. For more information, visit http://allmedmd.com.