AliCare Medical Management (AMM) (www.alicaremed.com), a leading provider of high-quality, clinically-based care management programs and a member of the Amalgamated Family of Companies, announces its ability to support health plans, consumers and providers through a seamless appeals system that covers clinical and administrative appeals, including denial of services related to mental health and substance use disorder (MH/SUD) treatments. Reviewing behavioral health coverage determinations are a critical part of the medical management system due to new federal and state parity laws that have been adopted in recent years.

AMM supports the integration between the general medical system and the specialized behavioral treatment system as an important way to improve financial and clinical outcomes.  AMM recognizes the efforts of The Kennedy Forum and the Parity Implementation Coalition (PIC) to raise awareness about the importance of covering behavioral health conditions as well as medical conditions.  Recently, The Kennedy Forum and PIC published the “Parity Resource Guide for Addiction and Mental Health Consumers, Providers and Advocates,” which discusses in some detail how the appeals process works, which is helpful to all stakeholders including health plans.

“Behavioral health problems such as anxiety, depression and addiction disorders are among the most common and disabling health conditions worldwide. Behavioral health often coincides with chronic medical conditions and significantly impacts health outcomes,” says Julie O’Brien, RN, BSN, President of AliCare Medical Management. “As a result, AMM creates and uses customized care treatment plans to address both the physical ailments and psychosocial challenges associated with each individual patient.  Additionally, AMM offers an appeals process which ensures all coverage determinations are handled appropriately.”

Over the past several decades, policy experts and consumer advocates have expressed concerns regarding how MH/SUD treatments are often carved out or not covered at the same level as medical or surgical care. To address the disparity, Congress adopted the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equality Act (MHPHAEA). The federal law, along with numerous state laws, is leveling the playing field for insurance coverage of behavioral health care alongside mainstream medicine. The Kennedy Forum and PIC’s Parity Resource Guide is an essential tool to assist both patients and providers in navigating the insurance and regulatory system.

“AliCare Medical Management is uniquely positioned to support payers, providers and consumers who may need to process appeals because of a parity violation,” notes Joel V. Brill, MD, FACP, Chief Medical Officer, Predictive Health LLC.  “AMM is unique in its ability to provide URAC-accredited Utilization Management and External Review programs that facilitate the appeals process, and customized services to support parity appeals pursuant to federal and state requirements.”

“Collaborative care is one important approach to bridge the gap between behavioral and traditional medical services, in part by improving care for common mental disorders in which primary care and mental health providers work closely together to assure effective primary care treatment,” says O’Brien, who also serves as the current President of the National Association of Independent Review Organizations (NAIRO). “Our goal is not only to empower health plan compliance with the parity regulation requirements, but also to foster real change and create new communication channels.”

Alicare Medical Management has established a reputation as an industry leader, in part because the following attributes.  AMM:

• Supports most levels of the internal and external review process, and coordinates reviews and appeals nationally for a variety of clients
• Operates on a 24/7 basis since 1995
• Holds four URAC accreditations for utilization management, case management, health call center and independent review, which helps ensure that AMM is following national quality standards
• Is licensed in all states, where required, as an independent review and utilization management organization;
• Supports specialty-matched reviews available in all disciplines
• Offers an extensive panel of physician reviewers in multiple states
• Provides specialty matched reviews in all disciplines
• Deploys a provider credentialing process that meets URAC standards
• Utilizes patient-specific, evidence-based methodology for reviews
• Is a founding member of the National Association of Independent Review Organizations (NAIRO)AMM partners with health plans, insurance companies, third-party administrators, trust funds, utilization management companies, hospitals and physician practices supporting programs with clinical expertise. The AMM physician panel consists of highly qualified and experienced providers in all specialties to perform a full range of essential services. Services include preservice determinations, first and second level appeals, medical claims reviews, bill audits, claims coding reviews, clinical editing reviews and handling unusual claim requests. AMM medical professionals supplement and enhance existing programs through access to the URAC accredited programs. 

  As a national leader in delivering customized medical cost management solutions, AMM is recognized for providing high quality services that promote cost effective care, patient satisfaction and optimal medical outcomes. AMM believes that quality Care Management is patient-centric, providing the best care for each patient within the framework of evidence-based medical guidelines and appropriate costs.

   

  For more information about AMM and its services, please call (800) 863-8688.

   

  # # #

   

  About AliCare Medical Management (www.alicaremed.com)

   

  AliCare Medical Management (AMM), a member of the Amalgamated Family of Companies, is a national leader in developing care management solutions that promote cost savings and patient satisfaction. AMM’s call center is open 24 hours a day, 365 days a year to provide maximum access and assure optimum program effectiveness. The company’s services include: 24-hour Nurse HelpLine, Utilization Management, Maternity Management, Case Management, Disease Management, Health Coaching and Wellness, Independent Physician Review, Medical Claims Review and Hospital Bill Auditing. AMM holds four URAC accreditations for Utilization Management, Case Management, Health Call Center and Independent Review.