Clinical Appropriateness Review
An abundance of peer-reviewed research exists documenting that a high proportion of specialty care procedures such as advanced imaging and interventional cardiac procedures may be inappropriate. According to these studies, inappropriateness estimates range anywhere from 10-40% depending on the type of service, provider dynamics and geography. Given the cost of these exams, the number of inappropriate procedures places a significant financial burden on our healthcare system.
As a core component of AIM's Management Programs, our clinical review process leverages widely accepted clinical guidelines and the latest medical literature to help ensure that members are receiving the most appropriate care. As part of this process, AIM collects relevant clinical data from ordering providers through our web portal or via the phone and conducts automated clinical reviews for requested services against AIM's guidelines. If the requested service does not meet medical necessity criteria, AIM's clinical staff will offer peer to peer consultations to ensure the most appropriate exam or treatment for the member.
AIM's clinical review platform is flexible and scalable meaning that it can be leveraged across various specialties including: