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Independent Medical Reviews
KEPRO has been providing accurate, impartial and evidence-based medical reviews for commercial and public program clients since 1985.
Contact KEPRO for Third Party Appeals You Can Trust.
Members, payors and employers need an independent, trusted source to help resolve member disputes under the Affordable Care Act. KEPRO has been at that table since 1985. We are URAC accredited in health utilization management, ensuring that our processes meet all federal and state external review requirements. We are also licensed to perform review in all 27 states requiring such licensure.
KEPRO is Up to Speed with New Regulations and Rules.
KEPRO’s program complies with all Affordable Care Act, Department of Labor, and State Department of Insurance requirements, as appropriate for health plans and employer groups.
KEPRO’s program provides:
- Qualified operational staff and peer reviewers with an in depth knowledge of the IRO industry
- Compliance with accrediting agency standards
- Compliance with ERISA requirements
- Quality management oversight
- Turnaround times that comply with state and federal requirements
- Credible, well documented review determinations
- Processes that meet the needs and time frames of each client
KEPRO has the Right Health care Professionals for Any Review.
KEPRO’s panel of more than 3,200 board-certified, actively practicing, specialty-matched reviewers and allied health professionals render medical necessity and experimental/investigational treatment determinations. Our reviewers must also have five years of post-licensure clinical experience and be in good standing in their communities.
Our Reviewers Represent a Broad Range of Medical Specialties.
Trained and credentialed to perform reviews and focus on appropriateness of diagnosis and treatment, they understand the current trends in their specialties. Specialists are recruited on the basis of their experience as independent clinical reviewers. Most reviewers are in active clinical practices. Many hold academic appointments.
All KEPRO Reviewers Undergo a Rigorous Credentialing Process.
Our reviewers are subject to primary verification of credentials and are re-credentialed every two years. We ensure the impartiality of our reviewers, verifying that they have no conflict of interest or financial considerations before assigning them individual cases.
How We Assign Reviewers.
We assign independent reviews based on:
- Same/similar specialty, dictated by the medical condition, procedure, or requested treatment
- State specific licensure requirements
- No involvement in the initial review
- No conflict of interest or financial affiliation with the member or the involved facility/provider
Our Reviewers Apply Nationally Recognized Clinical Criteria.
They utilize MCG® or InterQual® which can withstand legal scrutiny, and current clinical practice expertise to make evidence-based determinations. The reviewer may render a decision to uphold the denial, modify the determination, or reverse the original determination.
We record the following information in the case and determination summary:
- Specific rationale, including why criteria were not met if the initial denial was upheld
- Date(s) of service being denied
- Date of the notice
- State-specific requirements depending on if the patient is covered under a fully insured plan
- Statement of KEPRO authority and responsibility to perform the review
KEPRO Performs Reviews On Time, Every Time.
It’s a commitment to service that made KEPRO the choice of thousands of organizations for almost three decades. And part of the holistic approach to health care management you won’t find anywhere else.