Physician Advisor Reviews

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.

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“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
Utilization review contains three types of assessments: prospective, concurrent, and retrospective. BHM expertly handles all aspects, including appeals.
Utilization Management
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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 relationships with 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.