Independent review organization

Independent Review Organization

BHM, serving as an outsider to your organization, offers
expertise that is independent of the
health plan, the hospital, and the patient.

In short, our sole purpose is to use all available expertise to evaluate cases
based on the most current evidence-based practices
and national, state, or local regulatory guidelines.

Contact BHM

“An independent review organization (IRO) acts as a third-party medical review resource which provides objective, unbiased medical determinations that support effective decision making, based only on medical evidence. IROs deliver conflict-free decisions that help clinical [patient care] and claims management professionals better allocate healthcare resources.” – National Association of IROs

Good question. Whether your organization is a health system or insurance company, IROs often build value by

  • Providing access to networks of doctors specializing in unique and complex care.
  • Lowering the cost of maintaining and recruiting in-house medical subspecialties and behavioral health experts for reviews.
  • Building more efficient, independent support for applying medical necessity criteria

Why Choose BHM Healthcare Solutions As My IRO?

Glad you asked, because BHM stands apart from most IROs in a number of ways.

Below are just a few. For example, hover over each and see how they benefit organizations, like yours:

Accuracy Check

17-point data entry accuracy check

Validating Completeness

Validating completeness of every request and synthesizing clinical notes BEFORE reviewer assignment means every review is based on accurate and complete records.

Turnaround Times

We meet our client times with 99.4% accuracy

Build your piece of mind

You remain in compliance with your accreditation standards and regulatory requirements.

 

Accreditations

NCQA (UM), URAC (IRO), and HITRUST

Build your piece of mind

BHM meets industry quality standards. NCQA-Accredited programs are eligible for automatic credit when they work with another NCQA-Accredited organizations.

Peer-to-peer conversations

Industry connection rates: about 50%. Ours: average 85%

85% connection rate

Reviewers speaking with providers allows providers the opportunity to fill in the details, nuances, and thinking behind their notes lead to improved provider relations.

Clinical Audit

Post-review clinical audit BEFORE going to client.

Highest quality determination

BHM’s clinical services team reviews each determination ensuring accuracy, completeness, and attention to detail; delivering the highest quality determination report back to you.

Complex cases

Like behavioral health care, are not complex to BHM.

The BHM Difference

Imagine your complex cases processed as easily and as accurately as your most typical requests.

That’s the BHM difference

 

Building Trust and Confidence

This level of service builds trust and confidence that decisions are both rational and equitable. Conducting diplomatic, effective peer-to-peer consults with the attending physician as needed builds stronger provider relationships for your health plan while ensuring all relevant case details are considered when making an appropriate determination.

Utilization management (UM) decisions, made by BHM Healthcare Solutions (BHM) designated reviewers, use nationally recognized criteria and are based only on appropriateness of care and services, including the existence of coverage. BHM does not compensate anyone for denying coverage or service, nor does it use financial incentives to encourage denials or the under-utilization of any needed medical service.

Behavioral Health & Medical Peer Reviews

Prior Authorization Medical Necessity Experimental/Investigative Workers Compensation

          Initial           Concurrent           Appeals           Retrospective

Pharmacy Medical Chart Review Utilization Management Peer-to-Peer Consults

BHM is current with HITRUST, URAC Independent Review: External and Internal, and NCQA Utilization Management.

Clinical Peer Review System™ (CPRS) is an independent software solution for the secure case review of in-house medical staff for the purposes of quality control, staff development, OPPE/FPPE process management, and regulatory compliance.

 

BHM’s P2P call coordinators bring support, transcription, and independent observation to the call and ensure a quick connection, an accurate summary, and an impartial confirmation of details. Oh, and an 85% connection rate.

Our PRS™ web portal is available 24/7 for entering cases.  Office hours include 9 am to 6 pm ET though additional off-hour processing time is available. Please email sales@bhmpc.com for information on special services.