GMCF Services

Medical Review

When an independent, external review is needed to validate medical review decisions or clarify clinical issues, you can rely on Alliant GMCF’s proven, integrated Medical Review approach to provide you with professional decisions based on sound clinical judgment and evidenced-based standards of care. Since 1970, our clinicians have conducted medical reviews for services across the continuum of care to determine medical necessity, appropriateness of clinical setting, and the presence of quality of care concerns. We adhere to strict URAC standards and only use Board Certified physicians. Whatever your review case needs, our dedicated and experienced staff will address them with sensitivity, integrity and dependability.

Utilization Management

We pair our URAC-accredited processes with our proprietary system, Quantum XL, to provide a consistent and efficient approach to comprehensive utilization management. By integrating clinical criteria and our customers’ policies, Quantum XL provides one location for all review work and:

  • Helps with fiduciary responsibilities
  • Streamlines the review process
  • Provides prior authorization reviews
  • Produces retrospective reviews and data analysis
  • Performs real-time and automated reviews
  • Identifies candidates for more intensive medical management
  • Reduces the administrative burden on providers

Case Study

In a case study of Quantum XL™ implemented for selected radiology procedures, our client was able to see that the prior authorization requirement substantially reduced numbers of claims for radiology procedures and resulted in a projected cost difference of $30.2 million over a 17-month period. Alliant GMCF provided the services and the information needed to effectively administer the programs.

Program Integrity

Our MedGuard® system of integrated software applications and services support health plan integrity functions to identify, recover, and prevent inappropriate payments for health care. MedGuardThese functions include detecting, investigating, and preventing fraud, waste, and abuse by health plan participants. MedGuard® uses a unique combination of formulas and clinical judgment to analyze claims and payment data to detect patterns of fraud or abuse. With MedGuard®, you never have to wonder if an honest mistake is costing you money or part of a larger integrity problem.

Quality Improvement

We provide a comprehensive, integrated platform of quality improvement tools and methodologies to help streamline workflow processes, pinpoint critical problems, and accelerate the rate of quality improvement of health care delivery. They include:

  • Focused Quality Studies
  • Consulting
  • Training and Education
  • Program Development
  • Program Evaluation
  • Quality Assurance
  • Provider Academic Detailing

Our experienced staff knows the health care environment and how to drive real-world change through project leadership. Past projects have included

  • Electronic Medical Records
  • Health Disparities
  • Payment Error Rates
  • Diagnosis-Related Groups (DRG)
  • Appropriate Care Measures
  • Medicare Part D (Pharmacy)
  • Care Transitions and Re-admissions
  • Acute Care Hospitalization
  • Patient Safety Programs
  • Infection Control/Prevention, e.g. MRSA
  • Adverse Drug Events
  • Prescription Drug Abuse
  • Wellness Campaigns
  • Acute Myocardial Infarction
  • Chronic Kidney Disease
  • Congestive Heart Failure
  • Community Acquired Pneumonia
  • Breast Cancer
  • Diabetes
  • Immunizations
  • Smoking Cessation
  • Atrial Fibrillation and Stroke
  • Influenza
  • Carotid Endarterectomy
  • Pressure Ulcers