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Utilization Review

“Approvals when appropriate and Denials that stick”

OMCA Philosophy

Utilization Review (UR) involves screening certain proposed medical procedures to determine if they are reasonably related, 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, ensuring 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 Case Managers and physician reviewers utilize the latest evidence based criteria in evaluating each UR submission. UR decisions made by non-clinical staff result in unnecessary procedures and denials that don’t stick.

URAC

As a member of a select fraternity that has chosen to be URAC accredited for workers’ compensation utilization management, OMCA has made the investment to ensure that appropriate requests are promptly approved while denials are thoroughly researched and scientifically supported. Several of our physician advisors are authors of workers’ compensation clinical guidelines and recognized nationally as leaders in their fields of medicine. URAC accreditation lets clients know that OMCA adheres to the highest industry standards as we help payers effectively control their medical costs and case reserves.

Peer Review

In addition to determining medical necessity, OMCA Registered Nurse Case Managers are specifically trained and uniquely skilled to identify questions of relatedness and compensability. Upon consultation with our client, a specialty match Peer Review may be undertaken before the UR process continues. Our Board Certified Physician Advisor Panel will provide a peer match physician who uses the latest scientific evidence to achieve the correct outcome in these questionable situations.

At OMCA, we have spent the last twenty years developing a Physician Advisor Panel whose credentials, experience and reputation (with regulators and employers) are second-to-none. We do not blindly select our Peer Review professionals from national Independent Review Organizations. Whether local or national, our reviewers are committed to applying the best medical evidence to control costs and manage reserves.

OMCA Specialty Match Reviewers are available nationwide in all medical areas including:

  • Addiction Medicine
  • Anesthesiology
  • General Surgery
  • Hand Surgery
  • Neurology
  • Neurosurgery
  • Occupational Medicine
  • Orthopaedic Surgery
  • Pain Medicine
  • Physical Medicine & Rehabilitation
  • Psychiatry
  • Toxicology
  • Urology

Contact Rosalie Faris, RN, BSN, CCM, COHN-S for further questions at rosalie.faris@omca.biz

From our Clients & Colleagues

Angela Harris Self-funded Employer

"OMCA is easy to communicate and work with. I don’t feel like a number when I inquire about a claim. They know the case and employee I am speaking of immediately. You really feel like you’re receiving personalized service."



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