Aligning care with best practices: clinical appropriateness review

This is an amazing era for medicine. New tests, treatments, and medications hold the promise of improving or even saving lives.

But not all innovations create meaningful benefits, and not all care that is administered follows accepted standards for care. The costs associated with care that’s not appropriate creates a burden on our entire health system, and can leave patients without the means to pay.

In the complex arena of health care, rapid advances in medicine make it hard for physicians to keep up with the latest evidence-based guidelines. However, variation from established best practices compromises efficiency, effectiveness, quality, and safety in care.

AIM can help ensure clinically appropriate care is adopted throughout your networks and member groups, and across today’s most complex, costly, and specialized clinical areas. Our clinical guidelines and pathways, supported by Applied Pathways® cloud-based technology, are the foundation of our clinical appropriateness review process.

Setting the standard for clinical guidelines

Development of our clinical guidelines and cancer treatment pathways is led by AIM medical directors, physicians highly qualified in their fields, engaged in a rigorous process of evidence-based literature review.

After reviewing the published literature, our medical directors consult with some of the country’s leading physician experts and independent subject matter experts. Our guidelines are then reviewed by an independent panel.

These guidelines are updated no less than annually, or more often when significant new evidence is published.

AIM clinical criteria have received national recognition. Additionally, we are involved in the development of appropriate use criteria for the Centers for Medicare & Medicaid Services (CMS) Appropriate Use Criteria Program, an advanced-imaging clinical decision support mandate for Medicare fee-for-service beneficiaries. To develop the criteria, we are collaborating with the CDI Quality Institute, a nonprofit affiliate of the Center for Diagnostic Imaging and a CMS-designated provider-led entity.


AIM performs three levels of clinical guideline development and governance:


Subject matter experts: building a reservoir of available research 

To assemble and build on the available evidence-based-care research, we engage practicing, board-certified physicians who possess clinical expertise in the respective guidelines’ domain, such as sleep medicine and radiology. These physicians serve as subject matter experts (SMEs) and contribute in several ways. For example, they couple their expertise as practicing physicians with analysis of primary literature, specialty society guidelines, and technology assessments.


Specialty review panels: supporting guideline development 

The formal governance of guideline development begins with specialty review panels. Chaired by one of our solution medical directors, each panel includes at least three board-certified physicians with expertise in relevant specialties. We select the panelists based on their proficiency in the clinical specialty or in health care research. Like our SMEs, our panelists perform numerous tasks: they assist with drafting guidelines, offer counsel on particular guidelines, and provide recommendations to the independent multispecialty physician panel.


Independent multispecialty physician panel: reviewing and approving guidelines

The independent multispecialty physician panel is an autonomous group that has final-decision-making authority for approving guidelines. The panel consists of at least seven board-certified practicing physicians and represents various regions, specialties, and practice settings. This multidisciplinary approach balances the input integrated in the development process, especially in regards to primary care, specialist, and subspecialist referral patterns and patient considerations.

Our clinical review process: getting to the right care

Our clinical appropriateness review model is focused on achieving the right care for the patient the first time and effectively avoids unnecessary disruption. Rather than simply denying requests for care that doesn’t initially appear to meet clinical criteria, we provide educational opportunities and transparency to the physician community as part of the clinical intake process, and through peer-to-peer consultations. Prioritizing efficient provider interactions and education leads to sustained behavior change, reduced care variation, significant savings, and high provider satisfaction.

Clinical innovation: why our work is never done

Medicine advances at a fast pace. Our team is actively engaged in reviewing, discussing, and analyzing medical advancements, breaking news, and new technologies. Moreover, we constantly examine our processes and tools to find ways to create new value for health plans, their members, and their providers.

Our approach to innovation:

  • Advancing our clinical solutions to focus on areas of rapid change and escalating costs, such as genetic testing, specialty drugs, and musculoskeletal and pain management
  • Developing new partnerships that drive more value for health plans and improve clinical decision support for providers
  • Automating the review process with a flexible, new platform that enables greater precision and an optimized review. A highly trained team supports the platform, which features an intuitive portal that empowers better clinical decisions and inspires behavior change.
  • Focusing on the most prevalent conditions affecting the US population, such as headache and lower back pain, and updating our processes to achieve impact where it’s needed most
  • Mining big data to uncover trends and practice patterns that can inform network management initiatives and benchmarks. By serving a large, national client base, we have developed a comprehensive source of provider behavior, generating insights into true practice patterns across the US and regionally.

AIM possesses the footprint and resources for you to introduce value-based reimbursement throughout your entire provider network.