At EK Health, we have partnered our strength in clinical excellence with our superior technology in Utilization & Peer Review, resulting in a highly refined process where clinical excellence is the emphasis. By ensuring a strong technological workflow, EK Health clinicians are able to focus on quality, defensible medical reviews without concern for meeting stringent deadlines.
EK Health currently holds URAC accreditation for Utilization Management and maintains established best practices consistent with the standards.
Certified to provide Utilization & Peer Review in all states, EK Health has incorporated state jurisdictional rules, evidence-based medicine guidelines applicable to each jurisdiction and client-specific rules into the system. The programmatic application of rules on the front-end of the process expedites handling, provides system-decision support logic and promotes decisions at the lowest level possible, thus reducing costs and adding efficiency.
- Prospective Review: Reviews for ongoing medical treatment are completed by EK Health UR nurses and peer review physicians following nationally recognized guidelines. Our efficient, paperless, proprietary process helps ensure prompt completion of all reviews.
- Pre-Certification: EK Health’s pre-certification program is administered by the appropriate medical professional using nationally recognized guidelines to authorize surgeries, determine in-patient hospital lengths of stay, and determine appropriate post-op supplies and services.
- Concurrent Review: EK Health UR nurses utilize applicable evidence-based medical guidelines such as ACOEM, ODG, MTUS, and Clearinghouse.gov to approve the length of stay during hospitalizations in Concurrent Review.
- Retrospective Review: EK Health conducts a retrospective review for medical necessity after medical services have been provided and for which approval has not been previously given. The retrospective review can be for any request for services or treatment provided but not formally requested.
- Retrospective Pharmacy Review: EK Health can provide a special review performed both by a PharmD and a physician to review complex cases where there are multiple drugs prescribed for chronic or catastrophic pain, and for any case where there are concerns about drug interactions or adverse effects. A thorough review identifies the justification for the medication, the monitoring that may need to be in place, and the appropriateness of the drug and its dosage.
- Peer Review: Turn to EK Health for Peer Review to support your first level in-house Utilization Review nurses and primary physician reviewers. The EK Health peer review physicians cover a wide range of specialties. They can provide true peer-to-peer reviews for specific medical conditions that go beyond the expertise of your primary level physicians. EK Health will provide quick response and thorough determination letters to complement your internal operations.
-Utilization Review Manager, a Major Insurance Company
-Attorney at Law for a Major Insurance Company's Claims Compliance and Training Department
-Nurse Consultant Manager, a Major Self-Insured Company, regarding an In-house Nurse
-Nurse Case Manager, a Major Self-Insured Company
-RN, Nurse Consultant, a Major National Insurance Company
-Hearing Representative, a Major Self-insured Company
-Claims Adjuster, a National Insurance Company
-Claims Manager, a Major Self-insured Company
-RN, Nurse Case Manager, a California JPA
-Claims Examiner, a Major Self-Insured Company