EdiPhy Advisors: Case Management & First Line Utilization Review Support

EdiPhy Advisors RNs are available to support hospital and other health care provider case management staff with first line medical necessity screening. Often, hospitals leverage our availability and expertise to fill gaps in on-site case management staffing during night and weekend timeframes. CMS requires the use of a screening tool (such as InterQual®) along with the complex medical judgment of an attending physician to ensure that services billed are medically necessary. EdiPhy Advisors RNs are equipped, experienced and skilled in providing accurate clinical insight and thorough documentation review to support hospital efforts to operate in compliance with complex Medicare and Medicaid rules and regulations. When facilities request nurse reviews, our licensed staff extract the clinical data needed from medical records to evaluate if the patient meets Inpatient Status using evidence-based criteria. If patient documentation does not support Inpatient Status, the licensed clinical professional can seamlessly refer the case to a Physician Advisor. EdiPhy Advisors manages and documents this process in compliance with health care law, as well as with CMS rules and regulations.

EdiPhy Advisors RNs provide expertise in Health Utilization Management (HUM). MedManagement first obtained HUM accreditation from URAC in 2008. The company has successfully maintained this accreditation since that time. URAC HUM accreditation ensures that organizations conducting utilization review create and follow policies and procedures that comply with URAC accreditation standards. URAC standards address patient and provider rights, regulatory compliance, information management security, clinical staff credentialing and oversight, and quality management processes that have been identified based on best practices in the industry.

EdiPhy Advisors RNs are passionate about and skilled in providing process review and consulting to facilitate improving case management processes. Our licensed clinical staff support client facilities by creating unique processes in support of existing compliance goals as well as the implementation of inter-rater reliability tools to validate process, evaluate staff compliance and identify training needs.

Our seasoned licensed staff provide practical utilization review and regulatory compliant solutions because we understand the requirements and practical dilemmas of the health care delivery system. We also understand that ongoing education of our own employees and of client staff is critical to our mutual success. We coordinate education sessions based on your client needs as well as broadly when regulatory changes are announced.

 

“It is not that I’m so smart. But I stay with the questions much longer.”

— Albert Einstein, 1921 recipient of Nobel Prize in Physics