Utilization management and quality review services

Acumentra Health offers utilization management (UM) and quality review services in acute care, ambulatory/outpatient care, long-term care, home health, and mental health settings.

Utilization management and review may examine

• where care is received
• whether treatment is medically necessary
• which procedures, services, and drugs are provided
• whether care is delivered in a timely manner
• how efficiently the care is delivered
• whether the patient receive the maximum benefit from the care

Case review

Acumentra Health’s reviewers conduct medical record case review to determine whether the care received was medically necessary and appropriate. Reviews may include utilization, coding, or quality of care issues.

Health care professionals review, assess, and evaluate patient care processes to ensure that a practitioner provides appropriate care. Our qualified health care professionals include

• clinically matched physicians
• RNs who are Certified Professionals in Utilization Review
• qualified mental health professionals
• certified Registered Health Information Technician and Registered Health Information Administrator coders
• other health care practitioners who review cases related to their specialty

Peer review

Peer review, an in-depth review of provider medical records as follow-up to a case review, is an important component of the quality-of-care oversight. The reviewer is generally from the same specialty as the provider that delivered the care in question.

Prior authorization

Acumentra Health provides prior authorization review—an assessment of medical necessity, appropriateness, and level of care before a patient is hospitalized or an outpatient procedure is performed. Acumentra Health issues certificates of need for services for children and adolescents, authorizing services prior to admission to psychiatric residential treatment.

Concurrent review

Concurrent reviews provide information on care presently being provided and can help to determine future care needs. Acumentra Health has conducted  concurrent review since 1984.

Retrospective (post-payment) review

Acumentra Health also provides retrospective, or post-payment review services. Post-payment reviews examine services provided in hospitals or other settings after care has been provided, a claim for payment has been submitted, and reimbursement has been paid. These reviews examine medical necessity, appropriateness of coding, and quality of care.

Past/present clients

• Centers for Medicare & Medicaid Services
• Oregon Department of Human Services
• Division of Medical Assistance Programs
• Addictions and Mental Health Division
• Seniors and People with Disabilities 
• Washington Department of Social and Health Services
• Medicaid Purchasing Administration