Utilization Review and Cost Outlier/Billing Validation

Utilization Review

The Foundation has over 30 years’ experience in providing utilization review services to providers and payors to ensure that the care rendered was medically necessary and appropriate, and met quality of care standards.  The Foundation served as the New York State appointed dispute resolution agent for utilization review issues from 1991-1996 (when the legislation sunsetted).  The Foundation is URAC accredited and follows all URAC guidelines as they pertain to the performance of utilization review services.

Medical records are reviewed by registered nurses and Board Certified physicians currently in active practice.

Our review staff is extensively trained on how to use and apply nationally recognized criteria in the utilization review process.

The Foundation ensures physician specialist peer review of all utilization and quality of care issues.

The Foundation serves as a subcontractor to the New York Medicaid Utilization Review and Quality Assurance agent, and has performed cost outlier review on thousands of cases for hospitals throughout New York State.

The Foundation has stringent procedures to protect the confidentiality of all health information submitted to us for review.

The Foundation has strict policies in place to guard against any conflict or perceived conflict of interest when assigning staff/physician specialists to a review. 

The Foundation is experienced in meeting stringent timeframes with respect to the utilization review process.

Cost Outlier/Billing Validation

Our team of health care professionals has extensive experience (over 30 years) in performing cost outlier reviews.  The scope of the review includes:

Medical necessity of the inpatient admission;

Medical necessity of the acute length of stay;

Coding and DRG validation;

Line-by-line review of itemized charges to ensure that all items/services charged were ordered and provided.

With our extensive experience in conducting cost outlier reviews, the Foundation is in a strategic position to assist providers and payors with a successful cost outlier review program.