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We developed the PHCS External Review Network (ERN) for use in states in which case reviews must be conducted by appropriately matched state-licensed providers to meet regulatory compliance. Our ERN allows us to conduct case reviews more cost effectively and in less time. The ERN includes over 170 actively practicing physicians that are licensed in their respective states.
Below are some of the most frequently asked questions from our External Review Network. If you have a specific question or desire
more information about a topic not covered here, feel free to contact us.
What types of reviews are performed?
What is the average length of time for the Participating Reviewer to review a case?
What is involved with training and how long will it take?
Why are the review procedures so complex?
Who is the American Accreditation HealthCare Commission/URAC?
Who is the National Committee for Quality Assurance (NCQA)?
How many cases will I receive each month?
Will the Participating Reviewer's name remain anonymous when reviewing cases?
Once a provider is participating in the ERN network, how is the provider reimbursed for their services?
Q: What types of reviews are performed?
A: The ERN Participating Reviewer will review prospective inpatient and outpatient cases, hospital admissions, concurrent reviews, (reviewing during hospitalization to determine the necessity of continued stay) appeals and retrospective chart review.
Q: What is the average length of time for the Participating Reviewer to review a case?
A: Standard Case:
- Maximum expected duration is 20 minutes over a period of one to two days.
- The Participating Reviewer examines case information provided by PHCS including case notes, a specific question to answer, and any clinical guidelines necessary to assist in decision-making. (Feel free to contact us concerning any suggestions you might have that would modify our policies to meet accepted practice guidelines.)
- The Participating Reviewer is able to make determination based on past clinical experience and knowledge.
- The review may require a telephone call to the attending provider to obtain additional clinical information.
Exceptional Case:
- Maximum expected duration is 30-45 minutes over a period of one to two days.
- Standard review, plus either a review of the medical record or a literature search.
- May be a retrospective chart review.
- Exceptional cases are reimbursed at a higher rate.
Q: What is involved with training and how long will it take?
A: Since many Participating Reviewers are new to the review process, PHCS provides an Administrative Handbook that provides instruction on how to process case reviews. It also provides Participating Reviewers the rationale for our review process, defines our expectations and provides instruction on how to obtain reimbursement for services rendered.
After reading the Administrative Handbook, Participating Reviewers take part in a fully reimbursed, hour-long conference call to discuss the review process. There is also an opportunity for Participating Reviewers to ask any questions they may have prior to their first review. The average training time is approximately 1 to 2 hours, although the length of time for reading and understanding the Administrative Handbook will differ for everyone.
Q: Why are the review procedures so complex?
A: PHCS provides a medical review service that makes medical appropriateness decisions for a number of different insurance carriers as well as for direct employer groups. We are required to be licensed in all states in order to perform Utilization Review.
We are also accredited by URAC and certified by the National Committee for Quality Assurance (NCQA). In order to comply with their standards and perform consistent reviews, we have developed formats and policies that must be followed. This is why, at times, we require the Participating Reviewer to call the attending provider and ask appropriate clinical questions as well as read the attending provider or staff a standardized script. All conversations are recorded through a PHCS supplied toll-free telephone line (this protects both the Participating Reviewer and PHCS). We also require that standardized notes be sent back to PHCS for inclusion in the PHCS Care Management system.
Q: Who is the American Accreditation HealthCare Commission/URAC?
A: The American Accreditation HealthCare Commission/URAC is a non-profit organization founded in 1990 to establish standards for the managed care industry. Their membership and governance structure includes representation from all of the constituencies affected by managed care including employers, consumers, regulators, health care providers and the workers' compensation and managed care industries.
Q: Who is the National Committee for Quality Assurance (NCQA)?
A: NCQA is an independent, non-profit organization whose mission is to evaluate and report on the quality of the nation's managed care organizations. To earn NCQA accreditation a health plan must report on its performance in selected areas, including member satisfaction, quality of care, access and service.
Q: How many cases will I receive each month?
A: The number of cases you receive each month will vary based on demand. Prior to receiving a case, the Participating Reviewer will first be asked if he/she has the time to accept the case.
Currently, PHCS estimates that a Participating Reviewer can expect two to six cases per month, although in states where same state licensure is required for review, the caseload may be higher.
Q: Will the Participating Reviewer's name remain anonymous when reviewing cases?
A: Once PHCS has received the case determination and notes from a Participating Reviewer, the PHCS Physician Review support staff enters that determination into our system. We then generate a Notification of Determination letter that is mailed to the enrollee, the attending provider and the facility on the next business day. The Notification of Determination letter states the name of the Participating Reviewer that made the case determination. In states where credentialing information is required by law, the letter also lists the state in which the Participating Reviewer is licensed as well as his or her specialty.
Q: Once a provider is participating in the ERN network, how is the provider reimbursed for their services?
A: In order to be reimbursed for your services, you will need to send a monthly invoice to the PHCS Corporate Medical Director at 1100 Winter Street, Waltham, Massachusetts 02451. The invoice should contain the following:
1. A list of cases reviewed for month, including the enrollee's name, case reference number and date received.
2. A second sheet of paper, on the provider's letterhead, with the total amount to be reimbursed for that specific month.
If there is a month in which you do not review any assigned cases, you are not required to send us an invoice for that month.
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