Initial secondary physician review of any payer including Medicare, commercial plans, Medicaid and self pay
Our physicians use their vast knowledge of utilization review criteria, their vast experience in utilization management, and strong clinical backgrounds to make sound determinations.
We provide prompt turnaround with a clearly stated and detailed determination, 365 days a year.
Our physicians have built strong working relationships with treating physicians and discuss all status change recommendations with the treating physician.
Commercial insurance appeals
Our physicians have an outstanding knowledge of Milliman Care Guidelines and Interqual Criteria.
We have found that with a detailed appeal letter that demonstrates a knowledge of the case, the standard of care and these utilization review criteria results in a high rate of denials being overturned.
In cases where Milliman or Interqual criteria were met, we have found that quoting the actual guideline precisely is very effective.
RAC (Recovery Audit Contractor) appeals and peer-to-peer hearings
Our physicians have worked hundreds of RAC appeals.
Our physicians have represented numerous facilities at peer-to-peer hearings with RAC medical directors and have obtained a decision in favor of the facility in over 60% of cases.
Administrative law judge hearings
Our physicians have vast experience with legal testimony and have participated in administrative law judge hearings and state Medicaid hearings.
Physician education, including in-person lectures
Our physicians have provided education to dozens of physician groups about admission status, coding, and most recently the Medicare Two-Midnight Rule.
Ongoing education is part of our core services and interactive lectures can be provided by our physicians in person or by webinar.
