Utilization & Peer Review

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.

 


"EK Health is considered the Gold Standard for Utilization Review. We can always count on high quality and timely decisions."

-Utilization Review Manager, a Major Insurance Company

"We have received our UR audit results from the California DWC auditors. We scored a 99%. Thank you for your assistance in providing the information required."

-Attorney at Law for a Major Insurance Company's Claims Compliance and Training Department

"You made a wonderful catch on a referral that was sent over for review. The system showed that neck was an accepted body part. This is a 2004 claim settled in 2008 by Stip -- the stip was for "right wrist, left wrist, right hand, and bilateral upper extremities." You brought the request for neck treatment to my attention after noticing the Stip did not include neck and I was able to discuss with the ACM and it was determined to deny the neck treatment as not part of the award -- this will save us a great amount of money -- Thank you for you diligence and great skills in reviewing and prepping cases."

-Nurse Consultant Manager, a Major Self-Insured Company, regarding an In-house Nurse

"I think EK Health is the best. I appreciate having this wealth of experience and information at my fingertips. The Physician Reviewers' opinions are clear and comprehensive. They are a continuing education for me. The R.N. Record Review is very helpful in summarizing medical reports in an orderly, legible fashion. Many medical reports are either poorly written or simply illegible, so this review is greatly appreciated. Also, there's never any anxiety about receiving decisions on time -- it's a given, every time."

-Nurse Case Manager, a Major Self-Insured Company

"One of our claims supervisors who is very hard to please told me he was impressed with EK's quick turnaround and comprehensive determination letters, and that he thought we had made the right decision in moving to EK Health for Utilization Review."

-RN, Nurse Consultant, a Major National Insurance Company

"Thanks -- UR report was received and thorough -- as expected."

-Hearing Representative, a Major Self-insured Company

"I am very pleased with EK Health, both for case management and UR. I tried using another company for UR, but EK Health's work is far superior. I will be sticking with EK!"

-Claims Adjuster, a National Insurance Company

"Thanks; you and EK are always so helpful."

-Claims Manager, a Major Self-insured Company

"I have worked with EK Health Services for many years and have found them to consistently provide high caliber, quality, utilization review services."

-RN, Nurse Case Manager, a California JPA

“Although the outcomes are not always what I want them to be, I feel confident that the reviewing doctor has made a fair assessment of the given situation with the information provided. The manner of follow-up and contact is consistently excellent. In my experience as an examiner, I have come across a number of unreliable vendors. And EK Health is definitely not in that category. I appreciate the documentation and explanations given by the UR physician. Finally, I look forward to any future referrals that may be needed because of the great service and product that you create. Keep up the good work!”

-Claims Examiner, a Major Self-Insured Company