Does something look wrong from a medical perspective and you need help putting your finger on it? Are you wondering if a claim has medical necessity, quality of care, experimental or investigational issues? GEM-MD is your solution to ensure that you are not paying for inappropriate services.

How does it work?

Submit your questions or concerns along with relevant medical records on GEM’s secure portal, where one of our specially trained nurses performs a primary analysis. This primary analysis report is then forwarded to our experienced physician for additional review and approval of recommendations. Typically, we either advise that the claim appears compliant and should be processed, or that an independent peer review is recommended to investigate potential issues. If the claim looks fine, we send you the primary analysis report and the case is closed in our system.

If our client chooses to proceed with an independent peer review, we send the claim to a specialized network of peer reviewers and organize the clinical information into a master document so that actionable items are clearly identified. We transfer this information to a negotiator who collaborates with our physician as needed. The preferred outcome is that an agreement is reached, and you are sent a repricing report so that you can issue payment. If the provider refuses to acknowledge the information StrataGEM can provide more options.

How long does it take and is there a minimum threshold?

The clinical primary analysis takes between 24-48 hours. The independent peer review can take up to 6 days, and potentially longer if the case is highly complex. See our guidelines for claim referrals and thresholds.

How much does it cost?

We do not charge for the primary analysis, it’s free. The independent peer reviews are billed at hourly rates, and the charges will be waived if we have a successful negotiation on the claim; if we negotiate after doing a review, our fee is contingent on the savings we are able to generate in keeping with applicable rate structure. This product is designed for our partners, clients for whom we process a solid base of claims with one or many of our services. Given the cost of these resources, GEM-MD is not meant to be a stand-alone product.

How is your approach to clinical reviews any different from other vendors?

Most reviewers just want to do a peer review. The GEM primary analysis ensures that you are not wasting your time and money on a claim without issues; if it is sent for peer review our experienced physician ensures that the reviewer focuses on the problem areas of the claim – this shortens the time needed for the review, lowering the corresponding cost.

Also, GEM uses this information to impact the claim directly. One of our experienced negotiators calls the provider to discuss the situation, an agreement is reached or a revised claim is submitted, a document is signed, and you are sent a repricing report so that you can issue payment.

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