Utilization Review manages medical aspects of claims in conjunction with ensuring injured workers are provided with timely and appropriate medical care. Over utilization of medical treatment is a driving factor in the overall cost of a Workers’ Compensation claim. SFUR, through the use of licensed nurses, board certified physicians and application of data driven evidence-based guidelines, addresses costs through a proactive approach.
Pre Authorization – Utilization Management covers the Medical Utilization Review/Utilization Management (UR/UM) component for Medicare Advantage, Managed Medicaid and other managed care plans is a critical function that requires medical depth, breadth and resourcefulness. Members of SFUR’s physician panel provide Utilization Review for Medicare Advantage plans and Medicaid plans.
Hierarchical condition category (HCC) ) relies on ICD-10 coding to assign risk scores to patients. HCC is becoming increasingly prevalent as the healthcare reimbursement environment shifts to value-based payment models. Along with demographic factors (such as age and gender), health plans use HCC coding to assign patients a risk adjustment factor (RAF) score. A patient’s RAF score predict costs.
SFUR has the qualifications and experience to provide Independent Review Organization (IRO) Services to health care providers Corporate Integrity Agreements (CIAs) with the Office of Inspector General of the United States Department of Health and Human Services (OIG) and the related Settlement Agreements entered into with the United States.