Evidence-Based Medicine: An Overview

The term “evidence-based medicine” has been discussed frequently, but what does it really mean? According to the American Academy of Family Physicians (AAFP), evidence-based medicine is, “the judicious integration of the best available evidence with clinical expertise and an individual patient’s values, preferences and unique circumstances.”

Evidence-based medicine is a popular topic in healthcare because of its many applications. In the shift from fee-for-service to value-based care, evidence-based clinical decisions are utilized to enhance management and reduce unnecessary admissions. Some doctors believe developing more evidence-based guidelines for physicians is a solution to the problem of unnecessary medical treatment. For medical reviews, medical records undergo evidence-based clinical review to make sure services adhere to specific clinical guidelines and regulatory requirements.

Aiding Independent Review Organizations

Evidence-based medicine is highly pertinent to independent review organizations (IROs). IROs utilize evidence-based reporting in conjunction with clinical research, regulatory requirements and practice guidelines to support their unbiased decision-making. By providing decisions about medical care that are based solely on medical evidence, they act as a reliable and neutral resource with an extensive and specialized knowledge of healthcare services.

The transparency achieved by utilizing evidence-based medicine can help hospitals and health systems improve efficiency and productivity, as well as increase patient satisfaction. Additional benefits include:

• Delivery of high-quality results to clients
• Increased clinical accuracy
• More comprehensive utilization reviews
• Unsurpassed adherence to strict compliance requirements

Physicians employed by IROs are active in medical practice and stay up-to-date on the latest evidence-based studies and services in their specialty. As noted by the National Association of Independent Review Organizations (NAIRO), they’re required to adhere to evidence-based standards, including:

• Licensed, credentialed and active clinical reviewers.
  • IROs have immediate access to physicians and allied health care practitioners who are at the vanguard of medical treatments and services. These physicians are active in medical practice and stay up-to-date on the latest evidence-based studies and services in their field of specialty.
• Decisions that are supported by the latest evidence in peer-reviewed medical literature.
  • Clinical reviewers are experts in their field, and many IRO reviewers are affiliated with or have relationships with medical centers of excellence and research hospitals, linking them to the latest knowledge and resources of accepted medical practices and treatments. After reviewing a case, IRO written determinations and rationales are supported with references from peer-reviewed medical research literature.
• Advanced, ongoing education and training.
  • The rigorous credentialing and reviewer training programs for IROs are designed to ensure access to reviewers who are knowledgeable of the most current, peer-reviewed literature and evidence-based medicine.

Exceeding Standards with MLS

At MLS Group of Companies, we know applying the best available evidence is necessary for a successful, comprehensive review. That’s why we ensure timely, accurate and evidence-based peer to peer medical reviews from a nationwide network of specialized physician reviewers and healthcare professionals.

Our broad physician network covers all specialties and subspecialties in most jurisdictions. We verify that all questions in the case are appropriately addressed through the use of correct criteria for that specific state or case. Additionally, our quality assurance team reviews all reports to confirm there are no medical inconsistencies or contradictions. We also perform an audit of the physician-provided report to confirm that the entire file was reviewed, the pertinent information was addressed and the decision is conclusive.

Learn more about the evidence-based services MLS provides and the clients we serve to get started on your claims resolutions.