Case Review Services, Medical necessity, Experimental/Investigational, Benefit Converage

One of the greatest challenges facing any payer in the healthcare industry today is ensuring that everyone receives the care they deserve, while at the same time, controlling costs. This is a daunting task in an environment that includes changing regulatory requirements, shifting standards of care, and the increasing complexity of medical procedures.

By working with IMEDECS for your case review services, you will save valuable time and money by receiving quality decisions ensuring your members receive the correct level of care.

The services you need – At IMEDECS, we recognize that every client is unique, and your needs differ from others. We listen to your needs, and work with you to develop innovative solutions to meet these needs. For more information on case review services, please see the explanations listed below
The experts you trust- Your case will be reviewed by a specialty matched board certified physician or allied health practitioner. IMEDECS is driven by the most extensive and experienced panel of healthcare specialists in the industry
The timeframe you depend upon – You dictate the turn around timeframe; ensuring you never miss a deadline
Your complete solution

Case Review Services

IMEDECS case reviews, performed by physician specialists, combine an evidence-based evaluation of the treatment in question with an expert opinion to address questions of experimental/investigational status, medical necessity and medical appropriateness.

Organizations choose IMEDECS to:

Support their healthcare decisions;
Promote cost effective healthcare;
Meet state and legislative mandates;
Provide second opinion options for their patients or insured members; and
Evaluate alternative therapies

MEDICAL NECESSITY

Reviewers consider national and health plan-specific clinical criteria or guidelines
Questions or disputes typically involve the cosmetic, custodial, convenience, educational or maintenance nature of the service vs. its medical necessity

To see a sample medical necessity report, click here.

EXPERIMENTAL / INVESTIGATIONAL

Expert opinion is informed by an evidence-based approach to the questions related to the experimental status of the proposed treatment/procedure
Reviews may involve complex diagnoses; disabling, progressive conditions; and terminal illnesses
Reviewers consider scientific evidence supporting safety, effectiveness and medical necessity of proposed controversial medical treatments and procedures
Written conclusions and rationale are supported with references from the peer reviewed medical research literature

To see a sample experimental/investigational report, click here.

BENEFIT COVERAGE

Coverage for a medical service, procedure or treatment has been denied for contractual vs. medical reasons
Involves appeals where the Certificate of Coverage is interpreted by the plan as excluding the proposed or disputed service
Reviewers are trained and experienced in health benefit contract interpretation

To see a sample benefit coverage report, click here.