Utilization Review
ESMSEF has over 40 years’ experience 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.
Medical records are reviewed by registered nurses and board certified physicians currently in active practice. Our review staff is extensively trained in how to use and apply nationally recognized criteria in the utilization review process.
Decisions regarding utilization and quality of care issues are made by board-certified physicians in the same or similar specialty as the issue being reviewed.
Cost Outlier/Billing Validation
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. 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