UPIC Medical review delves into the medical necessity of a drug, diagnosis, procedure, or piece of medical equipment. This is where the process and reasoning of the medical professional in question is scrutinized and examined.
Medical review can be done for any type of healthcare provider/supplier including private practices, hospitals, Managed Care Organizations (MCO’s) and more.
A provider can be put under medical review for any number of reasons:
During medical review experienced nurses and clinicians review documentation to evaluate whether procedures, treatments, or billing is suspect. They will look for the following things:
Example: During data analysis of a private medical practice it is found that they have an unusual number of cases involving high blood pressure. In each instance patients are seen by the doctor in their office and prescribed medication. During a medical review of patient charts nurses note that almost all patients for which high blood pressure medication was prescribed show the same blood pressure. This improbable similarity between patients may become a piece of evidence and prompt UPIC investigators to interview select patients to gain further information. In the investigation it is found that many of those patients had no need for high blood pressure medication and the “treatment” had no other purpose than to collect payment. We have seen cases where patients whose blood pressure was not even checked during the visit but who were “prescribed” medication to treat high blood pressure.
In theory, almost anyone could review the medical records of a given provider and note unusual instances of treatment or suspicious patterns. Practice, however; is far different from theory.
A medical review conducted by someone with little or no medical experience will manifest only the most blatant instances of fraud or abuse. First-hand knowledge of medical procedures is prerequisite to property conducting a medical review.
At IntegrityM, we have a full team of nurse reviewers and certified coders with experience working on ZPIC and PSC contracts. Our Medical Director has worked as a licensed and board-certified doctor, meets all UPIC SOW requirements, and has extensive knowledge of Medicare and Medicaid programs.
Our UPIC Medical Review team is available to lend their expertise to the right operations. Call us at (703) 683-9600 or click here to contact us online to learn more about our capabilities or to discuss partnering opportunities.
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