UPIC Medical Review Services

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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:

  • Aberrant spikes in billing discovered by data analysis
  • Conducting an unusually greater volume of business than similar sized competitors
  • Logged hours exceeding reasonable expectations (e.g. 30 hour work days)
  • Services that may or may not have been rendered
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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:

  1. Whether the reported treatment aligns with treatment rendered
  2. Services rendered were reasonable or necessary based on the diagnosis
  3. Documentation is complete and follows standard medical practices
  4. Documentation supports the procedure code or level of service billed

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.

UPIC Medical Review requires subject matter experts

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.

Reviewers must

  • Be familiar with medical practices, procedures, and diagnoses
  • Understand numerous medical conditions, and be able to discern between degrees of severity, to judge whether the actions taken were appropriate
  • Know proper medical billing codes and how they relate to one another in order to spot instances of “up-coding”
  • Understand what actions would normally be taken during patient examinations for a vast array of conditions to decide whether action taken by the doctor was unusual
  • Be able to spot when unnecessary steps, procedures, diagnoses, or other means were taken
  • Notice unusual similarities between patients
  • Spot fabricated or inflated patient records

UPIC Medical Review Team at IntegrityM

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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