Physician Reviewers

Physician Reviewers

AFMC Seeking Physician Reviewers

For the past 50 years, AFMC has performed peer review services in the state of Arkansas. Arkansas Medicaid contracts with AFMC Clinical Services to perform reviews for medical necessity. Prior Authorization requests and a specified selection of medical records for Retrospective reviews are requested to review to ensure (clients) beneficiaries receive appropriate medical services. Reviews ensure that Medicaid funds are well spent and not the subject of fraud, waste, and abuse. 

Trained nursing staff perform the initial medical reviews. If the nurse cannot approve, the medical record is referred to a physician for further review. No review can be denied without a licensed medical doctor completing the review.

Providers may request a reconsideration if they disagree with the denial decision and may submit additional supporting documentation. Reconsideration reviews are performed by a medical doctor who most closely manages the medical service provided, which is often a specialist or subspecialist. Specialists must be board certified in their specialty and licensed by the Arkansas State Medical Board.

Medical reviews for reconsideration are performed by doctors, on their own time, from the comfort of their homes with a specified turnaround time to ensure contract timeframes are met. Records are housed on a secure portal, which is accessed from the physician’s personal computer. The physician reviewer responds in writing to specific questions, streamlining the time to complete each review. Physicians use their medical experience and knowledge to evaluate for medical necessity. Reviews are not medical decision-making but determining if the services provided were medically necessary and should be covered by Arkansas Medicaid. 

Payment to the physician reviewer is based on a per-review rate determined by the average time it takes to complete the review and the complexity of the case. Review rates specific to the type of review are made available to AFMC-credentialed reviewers. Physicians find that the reviews are a rewarding use of their medical expertise and easily completed at home, that AFMC staff is responsive to the reviewer's needs, and that the compensation is sufficient for their personal needs. 

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Additional Info

Clinic Name : Arkansas Foundation for Medical Care

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