|
URAC Accreditation:
PRN is accredited under URAC's Health Utilization
Management Standards, Version 4.2 and Workers' Compensation
UM Standards, Version 3.0. We need the help of all our
Physician Advisors to stay in compliance with URAC
guidelines. More specifically, each Physician Advisor
will need to complete a form of reviewer training. We
have several options:
1. On
www.cmeprogramonline.com under URAC, you may log on,
take the pre-test, read the material, and take the
post-test. This will be without cost to you and will
take approximately 25 minutes.
2. The other option will
provide you with 5 Category 1 credit hours and
Certification as a Physician Advisor.
(Each participant will receive an official certificate
to display this accomplishment.) The Physician
Advisor Certification and Continuing Medical Education
Program is set-up for self-study either online at
www.cmeprogramonline.com
or by study manual. This program has been approved by
the Banner Health System CME Advisory Committee, and has
received extremely positive feedback from several PRN
Physician Advisors, such as yourself. As a PRN Physician
Advisor, you will receive a 20% discount on the program
fees, reducing the fees to $100. If interested in
ordering a program manual, please call me, and I will
fax you an order form, or if interested in taking the
program online, please complete the registration on the
program website.
Evidence-based Criteria:
PRN reports will include
recommendations based primarily on evidence-based
criteria (medical research) and standards of care in the
medical community.
Evidence-based criteria consists
of abstracts, journals, and articles with the most recent findings, trends and
procedures on specific medical issues.
Generating and using the most up-to-date criteria will
create the strongest relationship between the reviewer’s
decision and the question at hand.
Presently,
PRN is in a transition period, as
we move from "guideline" criteria to evidence-based
criteria. Evidence-based criteria uses up-to-date
research sources relevant to specific specialties for
the evaluation of medical necessity. The criteria is
up-dated on a quarterly basis, rather than every two
years like Milliman & Robertson. Evidence-based criteria
are developed with involvement of appropriate physicians
and other providers with current relevant knowledge.
|
The
purpose is to ensure that
PRN physician reviewers utilize explicit clinical review
criteria that are current, reviewed on a regular basis,
and available to support recommendations.
Several advantages include:
- More current status of medical practice
- Information is provided by leaders in the field,
typically university affiliated academicians and
researchers.
- Reports are peer reviewed by national stature editors and reviewers.
- Criteria benefits from wide-spread input (multi-center and national).
- Provides opinions not covered by usual generic criteria.
- Criteria is more definitive in difficult reviews.
Disclosure:
The specific criteria used will be
disclosed in the Physician Reviewer’s final written
report.
For clients:
We will continue to address appeal
questions concerning unmet criteria such as Milliman &
Robertson or Interqual, however will need a copy of the
unmet criteria. With a copy of the unmet criteria PRN’s
reviewer will be able to address why the specific
patient’s situation either meets or does not meet the
criteria. This will allow for a more logical and to the
point report, because the reviewer will know exactly
what needs to be addressed and why.
For PRN Reviewers: When
time is of the essence, PRN will assist in gathering
relevant research documentation.
Psychiatric Case Management: There have been
some questions concerning the focus on case management
reviews. The PRN physician reviews the case material and
discusses the case with the attending, addressing the
questions at hand. The PRN reviewer will discuss issues
such as the comprehensive mental health evaluation,
treatment plan, treatment importance, medication,
effectiveness of treatment appropriateness, family
interaction, family therapy, and reasons why lesser
levels of care are or are not feasible. In addition,
what must be done to achieve eligibility for lesser
level of care will be reviewed. Concurrence is
established with the attending physician and continued
stays recommended when appropriate. PRN conducts these
types of reviews and will tailor programs to meet
special needs, including medical case management.
Forensic Services:
A "Forensic Review" is any requested service having to
do with the application of medical knowledge to legal
matters. The review process would likely be conducted
for the purpose of considering issues that will be the
focus of formal dispute resolution such as mediation,
arbitration, or matters before a court of law. Issues
and services which might be requested include case merit
evaluations, identification of potential issues, medical
records review, diagnostic evaluations, deposition
appearance, interrogatory response, literature search
and analysis, verbal or written reports, and expert
witness testimony
|
