HCRG provides a comprehensive and clinically robust Utilization Review Program nationwide. The program is engineered to expedite care, prevent delays and obtain clinical outcomes through the use of Medical Best Practices, Nationally recognized Evidence Based Guidelines, and State Specific Legislations.
• Prospective Review
• Concurrent Review
• Retrospective Review
• Peer Review
• Medication Utilization Review
• Specialized Utilization Review
• Medical Chart Review
• IMR Management
• Deferral Management
Led by a Medical Director and a Chief Nursing officer, HCRG utilization services are managed by a team of experienced, certified, and credentialed clinical professionals including Registered Nurses, Medical Doctors, and Certified Coders. With a team of over 120 peer review practicing physicians, we are equipped to handle all areas of specialty.
Our clinical team utilizes collaborative approved, evidence based guidelines and state specific rules to review medical treatment plan in alignment with injury and arrive at determination decisions. We conduct peer to peer discussions when necessary. Our approval has and continues to be successful. Our peer to peer communication, clinical experience, and collaborative approach have resulted in on-time UR decisions, lower medical costs, and a high level of care.
OUR UR WORKFLOW
Our UR Workflow is designed to be efficient and accountable. We understand that UR is time sensitive and all the steps in our workflow ensure that the UR request is properly attended to in an accountable manner. In each step, a team of well-trained staff with specified protocols execute their specific tasks to achieve required results. The workflow is updated continuously based on legislative, administrative and client driven changes.
OUR SOFTWARE APPLICATION
Our Utilization Review program is powered by our web-enabled Proprietary Software Application Suite MedSpectra-UR. MedSpectra-UR is designed to automate UR critical work processes, serve as data repository, and comply with state rules and regulations while adhering to URAC standards. Our software application provides us with a state of the art ability to produce specific reports.
MedSpectra-UR is organized to seamlessly integrate with Bill Review Software applications to facilitate payments of bills. It also has the capability to integrate with MPN and PPO networks as needed.
DENIALS AND APPEALS MANAGEMENT
We understand there are some utilization review decisions that will end up in denials and/or appeals. We have a State Specific Denial and Appeals Management process to ensure that the injured person is able to manage the denial and appeals for the best medical necessity decisions as fast as possible.
MEETING STATE AUDIT STANDARDS
HCRG and its UR clients have been audited on multiple occasions and we have always passed all the rigorous audit standards. Our operations are managed utilizing State specific rules and URAC driven policies and procedures. Our continuous quality improvement process has specific requirements in place to ensure compliance with standards and regulations.
UR BUSINESS EXCELLENCE
Business excellence is our hallmark. We understand the results required by our clients and all the stakeholders. We have put the following in place to ensure excellence in services delivery:
• Collaborative approach to work with claims management
• Detailed determination letters with evidence based guidelines
• Denial/Appeal Management Process
• Deferral Management Process
• Independent Medical Review Management Process
• Real time communication management process
• Fraud prevention protocols
• Reporting schedule
Reports: Our reports can be customized, some of the most used reports include:
• Cost savings and ROI
• Timeliness, timeline tracking/notification
• Request category
• Turnaround time
• Continuous education in regulation changes
• Certified, credentialed and highly trained team
• Our own proprietary software serving as data repository
• Ability to provide customized reports fast
• Our ability to identify high cost areas in claim life cycle
• On time delivery of UR decisions
• High ROI
• Ability to profile providers for over utilization over prescribing, and unsafe prescribing.
6571 Altura Blvd.,
Buena Park, CA 90620
“HCRG’s Utilization Review Service is approved to operate by the California Department of Industrial Relations”