“Approvals when appropriate and Denials that stick”
* Staffed by Registered Nurses with Case Management Certification
* Nationwide Review
* All Physician Advisors Board Certified In Their Specialties
Utilization Review (UR) involves screening certain proposed medical procedures to determine if they are medically necessary and appropriate based upon established review criteria. This includes prior authorization for hospital admissions, all surgeries and diagnostic studies and concurrent stay review to ensure that patients are discharged from the hospital when the level of service they are receiving no longer requires inpatient care.
At OMCA, UR is not merely an administrative function. Our registered nurse and physician reviewers utilize the latest evidence based criteria in evaluating each UR submission. UR decisions made by less qualified staff may result in unnecessary procedures and denials that don’t stick.
Approvals / Denials
OMCA’s registered nurse case managers are specially trained and uniquely skilled to promptly approve appropriate requests for medical services, when supported by nationally recognized criteria.
When the requested service does not meet criteria, the request is referred to our in-house board certified physician reviewer. If the reviewer determines that the service is not medically necessary, the denial is supported by written evidence based documentation and our client, the patient and the treating physician are promptly notified.
Treating physicians/patients have the statutory right to have any denial appealed to a specialty match provider. In these situations, OMCA has the request reviewed by a specialty match Board Certified reviewer who will render an independent opinion on the requested service.
These procedures ensure that the patient receives the right care while helping payers control their medical costs.
Frequently the UR process identifies patients whose outcome / recovery can be improved through nurse consultation and support. Most often this process lasts 3-6 months and involves frequent interaction between the patient and OMCA clinical staff. Outcome Enhancement involves the following areas and helps ensure the best medical outcome.
1. Patient Accountability
2. Identification of Post Operative Complications
3. Co-morbid Conditions (e.g. Diabetes, Obesity, Cardiovascular , etc.)
4. Pharmaceutical Compliance/Complication
5. Recovery to Appropriate Benchmarks
Accessing OMCA’s UR Services
OMCA provides UR services to carriers, third party administrators, self-funded employers and excess/reinsurance carriers. These services are provided nationwide and can be acquired on a stand alone basis or in conjunction with other OMCA programs.
Contact Rosalie Faris, RN, BSN, CCM, COHN-S for further questions at firstname.lastname@example.org
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