Medical Review BPO: A case study

Let it be any business, companies are always looking into ways to reduce cost and improve their service level and this is applicable to companies engaged in the business of providing health insurance, as well. The health insurance companies including health plans, medical management companies and third party administrators (TPA) are always struggling to reduce cost, improve efficiency and quality of the service and to meet the statutory compliances norms that are dynamic in nature. The struggle becomes more rigorous when it comes to reviewing medical necessity, pre-authorization and claim appeal requests.

Medical Review Outsourcing. Image courtesy

AIIMed Healthcare Management, a leading Independent Review Organization cited ways on how healthcare payers can reduce cost and improve their efficiency and quality by outsourcing reviewing works to IROs. The case study gives many reasons as why healthcare payers should turn to outsourcing their reviewing processes to established IROs.

Challenges faced by Healthcare payers

Often health payers face challenges in reducing the cost and to improve quality when reviewing the medical necessities, pre-authorization and appeal requests. In order to maintain the quality and to cater to different needs of the members, the organization deployed health plan medical directors for reviewing such appeals and requests. This method started proving to be harmful for the firms as it reduces the quality time of directors. They found that directors are not able to devote their time to other key functions that is of more value to the organization. It was also not easy to find directors who have the expertise to review all kinds of medical records and claim requests.

This prompted them to think about outsourcing the process to IROs. The firms strongly believed that by outsourcing they will be able to utilize the medical directors in areas where their expertise are required.

IRO Solution from AIIMed

AIIMed IRO service helps the health payers to accelerate the process of reviewing medical services and improves the quality by providing more evidence based medical reviews. Their in-house doctors and clinical researchers are available to provide free consultation on cases through online chat.

AIIMed software helps the clients to constantly monitor the status of any cases, download automatic reports and send and receive cases electronically any time through their online secure platform. They also enable collaboration with other professionals through peerpoint network and provide free access to their knowledge base which will help the clients in making quick decisions.

AIIMed offers clients reduced turnaround time and superior quality for every medical review. Clients will receive customized services and support all through the contract term.

Benefits by outsourcing medical reviews for health payers

By outsourcing medical review, pre-authorization and appeal requests

  • The payers were able to cut costs and increase their productivity
  • Helped them to deploy their internal staffs to focus on high level tasks such as policy development, service support and to meet the regulatory compliance standards
  • It also helped the firms to reduce the turnaround time in reviewing the requests.

A number of growing health plan players is adopting this strategy of outsourcing medical review process to established IROs.  But in the due process, the firms should provide due diligence in selecting the right IRO partner for them. They have to select IROs that have made necessary investments in technology and medical resources.

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