Understand Review Standards
To get the most from your outsourced medical reviews, you need to have a clear understanding of the review standards, including contract / plan language, policy / guidelines, and standard of care.
Contract / Plan Language – This typically refers to general definitions such as “Medically Necessary” or “Experimental / Investigational” and is not specific to a particular treatment or procedure. This can also include exclusion language, and occasionally, contract language specific to a particular discipline, such as services pertaining to fertility, obesity, or therapy.
Policy / Guidelines – This typically refers to procedure or treatment specific criteria or positions. This can include standard of care guidelines, such as MCG or InterQual, or NCCN and CMS guidelines available to the public.
Standard of Care – This includes a discussion of the standard of care in a particular medical community and will be supported by peer review literature.
Any combination of review standards can be chosen for your review but it is important to make your request an accurate reflection of what material you want considered in making the determination. If it is imperative that the policy criteria are adhered to, the policy should be the only review standard selected. You always have the option to ask additional questions regarding patient specific circumstances or the standard of care, but by choosing policy only, you are ensuring that the determination will be based on the policy.
Make Your Questions Specific
To make your reviews more effective, be as specific as possible in your questions. Avoid words like “lab testing” or “procedure” if possible, instead replacing with “vitamin D level” or “reduction mammoplasty”. This reduces the opportunity for error and focuses the reviewer on exactly what is in question. In the case of level of care or length of stay reviews, it is helpful to include dates defining the period under review, or specifically listing what level of care is under review, such as “partial hospitalization”, “inpatient level of care”, or “residential treatment”. If you are in need of specific information, it is good to ask questions as specific as possible to that information. Your Independent Medical Review partner can help you formulate these questions.
Choose The Appropriate Specialty
Choosing the appropriate specialist to provide a comprehensive review is very important in getting the best results from your reviews. For example, choosing the specialty of genetics should be avoided if at all possible. Geneticists will almost always choose to approve testing despite the fact that it will likely not change patient outcomes, because their job is such that they diagnose. For example, if Marfan’s Syndrome is in question, cardiology would be a more appropriate specialty choice than genetics. The same is true for radiology vs. orthopedic surgery (for muscoskeletal imaging) or OB/GYN (for mammography-related procedures). It is also important to get as specific as possible, whenever possible. For instance, careful selection of “interventional radiology” vs. “radiation oncology” can often lead to a more complete review.
Conclusions
Getting the best results from your medical reviews depends on the choices you make when you submit the review. By understanding the review standards, making your questions as specific as possible, and choosing an appropriate specialty you can ensure that you receive the most complete review and an evidence-based, unbiased determination.
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