DRG Claims Service provides expertise in identifying, correcting, and obtaining verified changes to DRG coding errors. SFUR licenses a customized pre-payment DRG auditing program that flags potential problem claims that are reviewed initially by nurses and if a clinical review is required, physicians perform the full clinical chart review.
SFUR Ensures DRG Claims compliance and integrity with provider-verified audit results with a customized service model for managed care payers.
Our clinical and business leadership brings decades of experience in cost containment in every payer-based and managed care setting.
Ongoing Professional Practice Evaluation (OPPE) Peer Review is used to make final judgement about quality of care in many quality assurance activities. OPPE evaluates practitioners who have been granted privileges and to identify those a practitioner’s clinical and professional competence.
Focused Professional Practice Evaluation (FPPE) Peer Review is used to make final judgments about quality of care in many quality assurance activities. Focused Professional Practice Evaluation (FPPE) is the follow up process to ensure that there is sufficient information available to evaluate a practitioner’s competence. FPPE is needed at the time of initial credentialing, as a result of the data evaluated during OPPE, and when additional data or reports indicate the need for a focused review of adverse events.
Utilization Review is the process of making sure health care services are being used appropriately, with high-quality care administered as economically as possible and in accordance with current evidence-based care guidelines.
As value-based reimbursement models become more prevalent, hospital utilization management will take on a more important role. SFUR provides prospective, concurrent, and retrospective utilization review in the provider community.
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.
Independent Medical Exams are examinations of an injured worker by a doctor that that has not been previously involved in the claim. An opinion is provided based on review of the medical documentation and a physical examination of the patient. The doctor addresses questions as posed by the requesting party.