The review of clinical services that have already been administered. It is also the review of medical files in comparison with treatment guidelines. In the latter case, information retrieved during a utilization review can be used as part of a system that creates the insurance companies guidelines for a given condition. When creating these documents, insurance companies not only use patient physical and histories, but also review how physicians, labs and hospitals handle the care of their patients.
UR Solutions possesses extensive experience in Managed Care Organization denials management. This includes both inpatient and emergency department denials. Claims may be rejected by insurance companies for a wide variety of reasons, but UR Solutions is experienced in handling them all. Our team deliberately and effectively analyzes each individual case, formulating the unique argument, which increases the likelihood for receiving an overturn.
Our highly trained attorneys are experts with years of training and experience in Medicaid appeals. Our familiarity with Medicaid’s regulations and criteria, as well as our clinical expertise and careful examination of medical records, makes us uniquely qualified to dispute these denials and allows us to provide increased revenue for our clients.
Administrative 3rd Level Appeals
Once we file an appeal, our team works diligently and aggressively to obtain an overturn at all costs. Our legal team examines each administrative denial and, utilizing its extensive experience, fights to receive an overturn by means of third level appeals. During this process, our legal team examines and applies all pertinent state and federal laws in order to ensure the receipt of an overturn and the recovery of important funds.
Actuarial Services/Data Analytics
We offer Actuarial Services to all of our clients. Our experts carefully review all data using robust data mining and screening techniques. We then organize these key performance indicators into weekly reports for our clients. These reports, which include recommendations, have helped our clients significantly increase efficiency and cash flow.