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Since 1985, KEPRO Board Certified physicians and clinicians have performed millions of Peer Review cases for organizations that demand the most diligent services.
KEPRO Reviewers Have Clinical Expertise Spanning a Breadth of Disciplines.
Our board certified physicians and clinicians are here to support your outsourcing requirements for medical peer review. Our peer review panel of experienced providers can perform specialty-matched reviews in all disciplines and provide clinical decision-making support. Using nationally recognized criteria, our panel will determine medical necessity or appropriateness of treatment.
The benefits of outsourcing medical peer reviews include:
- Access to all specialty physicians
- Removal of all opportunities for conflict of interest
- Facilitating a culture of cohesiveness among hospital physicians
- Objectivity and consistency of reviews
- Defendable conclusions
- Useful and actionable findings
Support for all state and federal regulatory requirements (including CMS) plus accrediting bodies such as URAC, NCQA, and JCAHO.
KEPRO’s panel of more than 500 board-certified, active, unrestricted, licensed, specialty-matched reviewers and allied health professionals render medical necessity and experimental/investigational treatment determinations. We also can call on more than 3,200 board certified (as appropriate), active, unrestricted, licensed health care providers that support specialty match review.
KEPRO Ensures Credibility, Compliance and Responsive Service.
KEPRO’s program complies with all DOL and State Department of Insurance requirements that are appropriate for employer groups. KEPRO provides:
- Qualified operational staff with an in depth knowledge of the IRO industry
- Compliance with accrediting agency standards and DOL/ERISA guidelines
- Quality management oversight
- Turnaround times that comply with state and federal requirements
- Credible, well documented review determinations
- Processes that meet the needs of the client
KEPRO Focuses on Finding the Right Reviewers for Your Specific Situation.
We accept requests by mail, phone, fax, or online, using our proprietary, web-based system, which we use to support all of our integrated care management solutions. Once all information, including supporting documentation is entered into our system, we select reviewers based on:
- Same or similar specialty, dictated by medical condition, procedure, or requested treatment
- Not involved 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.
To make evidence-based determinations, specialty reviewers may employ MCG® or InterQual®, both of which can withstand legal scrutiny. As active providers, they also consider current acceptable practice guidelines. The reviewer may render a decision to uphold the denial, modify the determination, or approve the request by reversing the original determination.
We record the following information in the case and in the determination letter:
- Specific rationale
- Why criteria were not met if the initial denial was upheld
- State specific requirements depending on type of plan
We also include clinical criteria used in making the determination:
- Date(s) of service being denied
- Date of the notice
- Statement of KEPRO authority and responsibility to perform the review
KEPRO Ensures Credible Quality Reviews On Time, Every Time.
Our specialty reviews have the built-in integrity to withstand the most intense professional scrutiny. We are URAC accredited in health utilization management and meet all regulatory requirements, including the most recent AHCA specifications. And we’re licensed to perform review in 27 states requiring licensure. Having all the bases covered in advance lets us focus on delivering determinations with the speed, efficiency, and exemplary service you expect from KEPRO.