EXTERNAL REVIEWS

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QUALIFICATIONS AND ACCREDITATIONS

  • URAC Accreditation as an Independent Review Organization (IRO)
  • ISO 9001:2015 Registration
  • Certified Women-Owned Small Business
  • HIPAA Compliance Program
  • CMMI-DEV Level 3 Accreditation

EXPERTISE

Medical and legal experts who make a difference:

  • Physicians: Board certified and licensed physicians in all specialties. Subspecialties
    in both surgery and medicine, including (but not limited to):
  • > Addiction Medicine
  • > Breast Imaging
  • > Cardiothoracic Surgery
  • > Chiropractic
  • > Genetics
  • > Infertility
  • > Neonatology
  • > Oncology
  • > Pain Management
  • > Physical Medicine & Rehab
  • > Psychiatry
  • > Urology
  • Pharmacists: Board Certified/Licensed
  • Nurses: Licensed/Certified in Coding
  • Allied Health Professionals: Licensed
  • Coding Specialists: Certified in Hospital & Provider Coding
  • Attorneys for Coverage Eligibility Reviews

INTEGRITY AND EXPERIENCE

  • Case review for Medicare Parts A, B, C, and D claims affecting over 40M beneficiaries
  • Oversight of Medicare‚Äôs national payment recovery program, identifying $370M in overpayments for return to providers in the first 4 years
  • United States Postal Service Office of Inspector General medical review of over 600 potential fraud leads since 2011
  • Workers’ Compensation case review with nearly $2.6 billion in Medicare set-aside dollars since 2011
  • External medical review for state health plans with over 170,000 beneficiaries
  • Clinical peer review for the Department of Veterans Affairs for 10 years
  • Department of Justice medical review with a single case resulting in a $77M fraud scheme conviction

EDUCATION AND SUPPORT

  • Legal team to help you interpret external medical review regulations
  • Easy electronic submission
  • Fast turnaround to meet federal/state regulations and your specific needs