|Medwork independent reviews, completed by our panel of specialty physicians, combine an evidence-based evaluation of the treatment in question with an expert opinion to address questions of experimental/investigational status, medical necessity, standard of care, and medical appropriateness.
|Types of Reviews
- Appeal of Health Benefit Plan Denials
- Medwork makes objective determinations on appeals covering the full range of disputes among enrollees, providers and health plans such as eligibility, contract interpretation, medical necessity and experimental/investigational treatment.
- Expert opinion is informed by an evidence-based approach to the questions regarding the experimental status of the proposed treatment/procedure
- May involve complex diagnoses, disabling progressive conditions, and terminal disease
- Reviewers consider scientific evidence supporting the safety, effectiveness and medical necessity of the proposed controversial medical treatments/procedures
- Conclusions and rationale are supported with references from the peer-reviewed medical research literature
- Pro Term Medical Director
- Workers’ Compensation
- Medical Necessity
- Reviewers consider national criteria and guidelines
- Disputes typically involve the cosmetic, custodial, convenience, educational or maintenance nature of the service versus its medical necessity
- Peer Review
- Sentinel events
- New physician hire
- Physician evaluation
- Risk management tool
- Quality assurance measure
- Credentialing or re-credentialing
- Protect and maintain Joint Commission on Accreditation of Health Organizations (JCAHO) status
- Prevent negative publicity, fines, lawsuits, public scrutiny, and damage to physician’s careers
- Help litigation teams and doctors in charge of hospital quality sort out the complexities of sentinel events
- Objective third party can provide peer reviews based upon medical evidence while improving the fairness of the process for the physician and the hospital
- Rescission Reviews
|Medwork’s independent review process:
- Is timely
- Offers remarkable customer service
- Focuses on the business of independent review
- Focuses on the individualized needs of our clients
- Focuses on clinical expertise and evidence-based medicine
- Is guided by an established Quality Assurance program that measures the quality of Medwork’s case reviews and customer service
|Upon Receipt of a Case:
|Medwork conducts a review of the case to determine if:
- A conflict of interest exists
- The case requires a standard or expedited review.
- The case is related to a clinical or administrative issue
- The case can be resolved through the independent review process
- The case refers to medical necessity or experimental/investigational treatment
If an organizational conflict of interest does exist, Medwork will return the case to the referring entity unless, upon full disclosure, consent is obtained to conduct the independent review.
Medwork Independent Review meets and exceeds industry standards in turnaround time. Reviews are completed quickly:
Organizations choose Medwork Independent Review to :
- Standard Turnaround Time is 5 to 20 business days
- Expedited Turnaround Time is within 72 hours
- Emergency reviews are available
Organizations choose Medwork’s Independent Peer Review to help:
- Provide healthcare that is cost effective
- Meet state and legislative mandates
- Resolve evidence-based issues
- Evaluate alternative therapies
- Interpret medical necessity
- Protect investor confidence
- Avoid high-profile lawsuits
- Avoid multi-million dollar fines
- Maintain their trusted reputation
- Protect physicians’ practices and careers
- Avoid scrutiny by state and federal agencies as well as other public organizations
- Fulfill the Joint Commission’s (JCAHO) requirement for focused and ongoing physician evaluation
|Medwork’s Review Process Insures That Every Appeal:
- Meets URAC standards
- Is reviewed in accordance with the best available evidence-based medicine
- Maintains and protects the privacy and confidentiality of medical information
- Receives a thorough review by a board-certified clinical specialist who has expertise in the medical specialty under review, and who is independent of any conflict of interest
- Is tracked through an established process that ensures the determinations are made within contract time frames
- The results are provided in a fair and impartial determination that is fully substantiated and consistent with nationally recognized standards
|Reviewer Selection :
|The board certified specialists represent all major medical specialties and sub-specialties and can provide a full range of clinical reviews. For each case, the reviewer is knowledgeable about the issue through actual, current clinical experience. Single reviewer and a panel of reviewers are available.
|Conflict of Interest Protections :
|Each reviewer signs a conflict of interest agreement and cannot review a case that they have professional, familial, financial, or other interest in. The reviewer shall not accept compensation for external review activities that are dependent in any way on the specific outcome of the case. Nor shall the reviewer have any involvement with the case prior to its referral to external review.
|Quality Assurance :
|Medwork’s documentation and tracking processes assure consistency in the review determinations regarding medical necessity and experimental treatments and include safeguards to ensure that decisions are being made fairly and consistently.
|Turnaround Time and Final Reports :
|In every independent review contract, Medwork has met or exceeded contractual requirements for appeal turnaround time. We offer multiple turnaround times to meet our clients’ needs that include standard, expedited, and emergency reviews. Medwork offers 24 hour on-call services.
|Confidentiality is of utmost importance. Medwork respects the confidentiality of protected health information and has strict policies and procedures in place, ensuring that confidentiality is maintained at all times. Records and information provided are limited to the information is that is necessary for the review of services and is shared only with the entities that have the authority to receive such information.
Medwork’s policy includes strict maintenance of confidentiality to ensure protection of rights and privacy of all persons whose medical records are submitted for review. Medwork provides timely and accurate reviews of medical records resulting in the statement of opinions of medical necessity, and quality standards of care that are consistent with evidence-based medicine. In order to process reviews, information is handled by Medwork staff, all of whom acknowledge the inherent right of each patient’s privacy. All staff members and contracted professionals uphold such material in the strictest possible confidence.
All medical and healthcare information provided to Medwork is for the purpose of conducting medical case reviews. This information may be contained in paper files or a file storage location. This information will not be disclosed or discussed outside of Medwork’s scope of business. It is kept confidential in accordance with applicable federal laws, state laws and regulations.
Only Medwork review personnel and staff members participating in the review process shall have access to the records. Only the client's designated contact person/authorized person shall receive the review and any supporting material from Medwork. Medwork‘s Confidentiality Agreement will be provided to clients and any other specifically authorized entity. All employees of Medwork are required to sign the Confidentiality Agreement as a condition of employment.
Our per-case fee is negotiated up front so you will know the cost before you send us a case. Our rates are competitive and reasonable. New clients are eligible for their first case review free of charge.
|Board Certified Specialties :
- Critical Care
- Family Practice
- General Surgery
- Immunology & Allergy
- Internal Medicine
- Medical Genetics
- Medical Oncology
- Occupational Medicine
- Orthopedic Surgery
- Pain Management
- Physical Medicine and Rehabilitation
- Plastic Surgery
- Preventative Medicine