BHM Healthcare Solutions

What BHM Healthcare Solutions does

BHM Healthcare Solutions, founded in 2002 and headquartered in Tampa, Florida, is a privately held healthcare services and software firm operating as a URAC-accredited Independent Review Organization (IRO). The company delivers utilization management, clinical peer review, physician advisory, medical director staffing, and accreditation consulting services to four primary customer segments: healthcare payers, providers, government agencies, and self-insured organizations. Service delivery is anchored by a national peer reviewer network of credentialed, board-certified physicians licensed in all 50 U.S. states across specialties including behavioral health, surgical, oncology, imaging, dental, pharmacy, and substance use disorder.

The company's technical core is PRS™ (Utilization Management Peer Review System), a proprietary cloud-based, HITRUST CSF r2-certified platform that consolidates case management, data validation via a 17-point accuracy check, push-notification workflow, and real-time review tracking. It is complemented by Clinical Peer Review Software, Business Intelligence Services with predictive analytics dashboards, and an end-to-end No Surprises Act IDR Arbitration support platform. Revenue is generated through four streams: professional services engagements (IRO reviews, accreditation consulting, CIA support, revenue cycle consulting), subscription-based software licensing (PRS™ and Clinical Peer Review Software on annual cadence), managed services (on-demand medical director staffing and behavioral health clinical consulting), and quote-based multi-year contracts. The go-to-market is sales-led direct enterprise engagement targeting compliance-driven healthcare buyers, supported by content marketing (Healthcare Awareness Series, Industry Insights blog), a weekly email newsletter, the LinkedIn Health Insider Group, and active thought-leadership coverage of CMS, HIPAA, and prior authorization policy. BHM maintains NCQA UM Accreditation, URAC IRO Comprehensive Review credential, HITRUST CSF r2 Certification, and NAIRO membership, which collectively function as significant regulatory entry barriers in payer-facing utilization review.

Name

BHM Healthcare Solutions

Legal name

BHM Healthcare Solutions

Website

https://bhmpc.com

Company type

Private

Founded year

2002

Operating status

Operating

Headcount range

51–100 employees

Short description

BHM Healthcare Solutions is a Tampa-based, URAC-accredited Independent Review Organization that provides utilization management, clinical peer review, medical director staffing, and accreditation consulting to payers, providers, government agencies, and self-insured organizations via a 50-state physician network and proprietary PRS™ software.

Ownership category

akta.pro rank

Product category

Healthcare Utilization Management and Independent Review Organization Services

NAICS

Offices of Physicians (62111), Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Offices of Physicians (except Mental Health Specialists) (621111)

SIC

Services-Health Services (8000), Services-Offices & Clinics Of Doctors Of Medicine (8011)

akta.pro primary industry

Clinical Quality Assurance (GCP QA, TMF/QMS oversight) (HLAGAKAI)

akta.pro secondary industries

Interoperability Standards, Profiles & Implementation (HL7/FHIR/IHE) (HLACABAA), Health Technology Assessment (HTA) & Reimbursement Policy Bodies (HLAJACAF)

Keywords

• Utilization management services
• Clinical peer review
• Independent review organization
• Medical necessity review
• Healthcare accreditation consulting

Headquarters

HQ city

Tampa

HQ country

United States

HQ region

North America

Offices1 record

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Marketing or Sales, Others

Revenue model

1. Utilization Management and Peer Review Services: BHM generates revenue through independent review organization (IRO) services, peer-to-peer appeals, physician authorization reviews, specialist reviews, complex reviews, nurse reviews, workers compensation reviews, and pharmacy reviews for healthcare payers, providers, government agencies, and self-insured organizations. Services are provided nationally through a credentialed physician network and include both internal and external reviews.
2. Accreditation and Compliance Consulting: Revenue cycle management consulting, NCQA and URAC accreditation assistance consulting, Corporate Integrity Agreement (CIA) support, and business intelligence services are provided as professional consulting engagements to healthcare organizations seeking to meet regulatory and accreditation standards.
3. Software Licensing — PRS™ and Clinical Peer Review Platform: BHM offers proprietary software solutions including PRS™ (Utilization Management Peer Review System) and cloud-based Clinical Peer Review Software, which are licensed to healthcare organizations for in-house case review, auditing, and quality assurance of utilization documentation and staff. These platforms integrate case management tools, provide push notifications, and offer real-time review tracking and reporting.
4. Medical Director Staffing and Oversight: On-demand Medical Director services offer expert oversight and staffing solutions, including transition staffing while HR recruits permanent directors, behavioral health clinical consulting, and on-demand clinical and treatment plan consults. These engagements provide licensed physician coverage to maintain compliance and operational continuity.

Pricing tiers

Go-to-market motion1 record

Distribution channels1 record

Marketing channels6 records

Core offering

BHM Healthcare Solutions delivers utilization management, independent clinical peer review, and medical director services to healthcare payers, providers, government agencies, and self-insured organizations. Offerings are supported by the proprietary PRS™ utilization management peer review software and a national network of board-certified, credentialed physicians licensed in all 50 states. Services include physician authorization reviews, peer-to-peer appeals, IRO services, NCQA/URAC accreditation consulting, business intelligence, and CIA compliance support.

Product overview

BHM Healthcare Solutions is a healthcare software and services firm offering a platform-plus-modules architecture centered around PRS™ (Peer Review System), their core utilization management peer review software. The platform is complemented by an extensive suite of services including utilization management reviews, peer review services, physician advisory services, medical director services, business intelligence services, and specialized consulting for NCQA/URAC accreditation, corporate integrity agreements, revenue cycle management, and No Surprises Act arbitration support. Services are targeted at payers, providers, government agencies, and self-insured organizations across the healthcare industry.

Differentiator

Problem solved

Functional benefit

Brands

• PRS™: Proprietary utilization management peer review software solution for case management, auditing, and quality assurance.
• Healthcare Awareness Series

Products and services

• PRS™ (Peer Review System) An intuitive, cost-effective cloud-based software solution that stores, organizes, formats, monitors, and prepares cases for Medical Director review. It consolidates data, minimizes errors, and optimizes workflow by integrating case management tools into one focused interface for utilization review and peer review processes.
• Utilization Management Reviews Comprehensive utilization management review services that assess medical necessity and ensure appropriate use of healthcare services, featuring 99.9% first-pass accuracy and 99.8% on-time turnaround. Targeted at healthcare payers, providers, and government agencies.
• Peer Review Services Independent clinical peer review services conducted by board-certified physicians across multiple specialties, including behavioral health and medical reviews for health plans, providers, and workers' compensation insurers.
• Independent Review Organization (IRO) Services Unbiased, expert-driven approach to claims review providing fair, evidence-based determinations for self-funded insurance plans, including medical necessity and appeals reviews under ERISA and HIPAA compliance frameworks.
• Physician Advisory Services

Quantifiable outcome

• 99.9% First Pass Accuracy
• +6 more outcomes

Named customers6 records

Segments4 records

Ideal customer profiles4 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

Feature6 records

Partnerships

One partnership is on record.

• Peer Reviewer Network (Licensed Physicians)coreOthersBHM operates an extensive Peer Reviewer Network consisting of licensed doctors in almost every state across the United States. The network provides behavioral health and medical review services to health plans, providers, workers' compensation insurers, and other payers. Recent client growth continues to expand opportunities within the peer reviewer network. Qualifications include current board certifications (if applicable), five years of active clinical experience, one or more state licenses, and predictable availability.

Scale indicators11 records

Recent moves6 records

Expansion highlights5 records

Broad incumbents

• Cotiviti: Cotiviti offers payment integrity, risk adjustment, and utilization management analytics for health plans. It competes with BHM in payment-integrity and UM-adjacent services, with a much broader analytics and technology footprint.
• Optum (UnitedHealth Group): Optum provides utilization management, care management, and clinical review services for health plans and providers, including through its acquisitions of Change Healthcare and naviHealth. It is a broad incumbent competitor to BHM across UM, IRO, and healthcare analytics.
• EviCore (Evernorth): EviCore is a large utilization management and specialty benefits management provider owned by Evernorth/Cigna. It competes with BHM across medical necessity review, prior authorization, and specialty UM, but at much greater scale and as part of a broader portfolio.
• AIM Specialty Health: AIM Specialty Health, part of Elevance/Carelon, provides utilization management and clinical appropriateness review across radiology, oncology, cardiology, and other specialties. It overlaps with BHM's UM services but operates at significantly greater scale and scope.

Direct peers

• Dane Street: Dane Street is a national peer review and IME provider serving payers, providers, and managed care organizations. It is a direct competitor to BHM's peer review and utilization management services with a comparable physician-network model.
• KEPRO: KEPRO is a quality improvement and care management organization offering utilization review, peer review, and IRO services to government and commercial health plans. It is a direct competitor to BHM in IRO and UM with similar government payer exposure.
• MCMC (Medical Consultants Management Committee): MCMC is an independent medical review organization offering peer review, utilization management, and IRO services to workers' compensation and health plan clients. It overlaps directly with BHM's core IRO and UM offerings.
• MedReview, Inc. MedReview provides independent peer review, utilization management, and clinical appeals services for payers and providers. It is a closely comparable specialty IRO competing with BHM in similar customer segments.
• AllMed Healthcare Management: AllMed is an independent review organization providing external physician peer review and utilization management to health plans and TPAs. It competes directly with BHM across IRO and peer-to-peer review services.

Others

• MultiPlan: MultiPlan provides cost containment, PPO networks, and payment integrity services to payers, including utilization review and negotiation support. It is a thematic peer in healthcare cost management but not a direct IRO competitor.

Market position

Strengths1 record

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• Xx.com/bhmhealthcare
• Facebookfacebook.com/bhmhc
• LinkedInlinkedin.com/company/bhm-healthcare-solutions

Compliance5 records

Revenue estimate

Valuation estimate

Number of profiles

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about BHM Healthcare Solutions