AllMed Healthcare Independent Medical Reviews: Q-elements Independent Medical Review Case Study.

The Facts
Company: Q-elements
Focus: Pre-Authorizations
Location: Lubbock, Texas
# of Monthly Claims: 3,000
# of Claims Sent for Review: 25 to 30 (1%)
Working With AllMed Since: 2001
Website: http://www.qelements.com

About Q-elements
Q-elements, 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.