Services

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 PRN continuously monitors and improves the array of services it offers to meet the industry’s growing demands.  New services are developed as needed to satisfy unique client requirements.  The following are PRN's standard services:

PHYSICIAN REVIEWS

Short Form Reviews:

Short-form reviews allow for shorter turn-around times, as the reviewers fax the forms, completed by hand, directly to the client.  These reviews are not transcribed, nor do they receive the PRN quality assurance check.  Therefore these reviews are offered at a lower rate.  Please note that short form reviews are limited to the basic specialties including Family Practice, General Psychiatry, OB/GYN, General Surgery, and Internal Medicine.

Standard Reviews:

Standard reviews are conducted by physician reviewers who dictate responses to specific questions posed by the client, or PRN Nurse Coordinators upon request.  These reports are type-written and undergo quality assurance screening measures.  The types of standard reviews include the following:

Pre-certification

Review of a request for medical services prior to a patient's admission, stay or other service or course of treatment, sometimes referred to as "prospective review" to determine medical necessity.

Concurrent Review of Medical Necessity:

Review of a request for service during a patient's hospital stay or course of treatment, sometimes referred to as "continued stay review", to determine medical necessity.

Retrospective Review of Medical Records:

Review for the purpose of certifying a service that has already occurred, or to review additional new information for a service that was not previously certified.

State and Specialty Matched Reviews:

Reviews conducted by state and specialty matched reviewers in compliance with client specifications, URAC, and/or state requirements.

Physician-to-Physician Discussions of Individual Cases:

PRN Physician Reviewers will contact the Attending Physician to discuss the case as required by state legislation, and AAHC/URAC Standards, or when requested by client.

Fee Code Analysis:

Review of CPT Code and usual and customary fee analysis including bundling and unbundling issues.

Plan Language:

Review of the purchased plan’s language to determine whether an intervention should or should not be covered.

Workers Compensation:

Review of requests for service conducted in compliance with State Workers Compensation, State Department of Labor and Industry Guidelines.

Experimental and Investigation Issues:

Review to determine whether a requested service is experimental and/or investigational.  Criteria can also be developed for investigational and experimental treatments, using a panel of medical experts.

Transplants and Oncological Interventions:

Reviews to determine the medical appropriateness of organ transplants, including stem cell transplants.

Z-Plan Expedited Review Process:

This review service allows for the fastest worldwide turn-around times, while maintaining compliance with URAC Standards.  The PRN reviewer receives the case and makes a decision immediately, prior to contacting the Attending Physician.  The requesting client will receive a verbal recommendation within hours of sending the case and will contact the Attending Physician to explain the determination and the reviewer’s rationale, in the case of a denial.  The Attending Physician then may request to speak to the PRN reviewer as a reconsideration.  In such a case, the Physician Reviewer will contact the Attending Physician on an agreed upon time and dictate an addendum.  PRN will transcribe, quality assure, and send the addendum to the requesting client that same day.  (This type of review has also been found to dramatically decrease reviewing costs and provide an increased role for the Attending Physician in the review process.) 

Expanded Services:

Expanded services are available to clients upon request on an “as needed” basis and include the following:

Forensic Reviews:

This service involves consultation on forensic services. (i.e. expert witness testimony, case merit evaluations, medical records review, diagnostic evaluations, deposition appearance; interrogatory response, and literature search and analysis.

Independent Medical Examinations (IME):

Locating out-of-network physicians and scheduling Independent Medical Examinations and On-Site Reviews on behalf of the client.

International Reviews:

Reviews involving any physician reviewer, provider, and/or patient located outside the continental United States.

Review of Proprietary Treatment Protocols:

Review of client's proprietary treatment protocols by specialty and/or state matched Physician Reviewers, as required by state law and/or client request.

Clinical Performance Audits:

Audit of health care facility's records in order to determine:

• Patient Quality of Care (Standards of Care)
• Appropriateness of Billing Procedures
• Cost Analysis

Independent Chart Reviews:

Review to determine the quality and appropriateness of care in a hospital or other clinical facility.

Location Matched Reviews:

Reviews requiring matching of physician reviewers by geographic locations more specific than state matched (i.e. by county or city)

Internal Audit by External Means:

This product has been developed to improve patient health outcomes by the measurement and assessment through external and unbiased chart reviews.  PRN Physician Reviewers will be given criteria to use when reviewing the clinic/hospital in question.  The physicians will review approximately 15-25 charts and will compare the patient care to standards, up-to-date sources of information (new procedures and treatments), performance of similar procedures in other organizations, length of patient stays, and overall patient care effectiveness.

Literature Searches:

Peer-reviewed literature may be included with cases reviewed by PRN physician reviewers, which allows for an evidence-based recommendation.

Literature searches may also be preformed for supplementary research.

Specialized Statistical Reporting:

Reports involving the statistics on the cases reviewed by PRN may be developed to meet state regulations and/or your company’s specific needs. (i.e. the number of denials per physician, per state, etc.)

MEDICAL DIRECTOR AND COMPLIANCE OFFICER SERVICES

State Matched Medical Director Services:

State licensed Medical Directors, as required by state law or requested by client, to oversee quality assurance and utilization review programs.

Medical Compliance Officer Services:

A PRN physician is appointed to oversee an organization’s Utilization Review and/or quality assurance functions, in those states where a medical director is not specifically requested.   These services are intended to comply with state regulations.

Associate Medical Director Services:

A consultation is held telephonically between a PRN Associate Medical Director and the Client’s Medical Director, Staff Physicians, and/or Nursing Case Management staff in efforts to discuss a particular case and develop a recommendation as to approval or non-authorization.

On-Site Medical Director Services:

A licensed, board certified doctor in PRN’s network will come on-site to your offices and facilitate medical director responsibilities, or you may choose a board certified physician on your staff to be hired by PRN as medical director allowing that medical director to have arm’s length.

PANEL REVIEWS

Telephonic conference reviews are designed to provide a method of review after all other levels of Utilization Review have been exhausted.  Many state laws now mandate panel reviews.  The various types of panels are as follows:

Panel Reviews involving Multiple Physician Advisors:

An independent panel review designed to comply with state mandated grievance processes.  The panel shall include, at minimum, the number of participants required by statute, who shall be health care professionals with appropriate expertise and who meet the state specific criteria.  (This service is the last step in the appeals process and is required by state law in Colorado, Missouri, Georgia, North Carolina, and several other states.  Panels are also performed on high profile cases or those that may go to litigation.  This is a preventive action/product taken to prevent lawsuits, and if brought to litigation, can be used for justification of the decision.)

Attorney Review Services:

PRN will gather panels of experts to answer questions on disputed claims.  Attorneys can take advantage of this service to get an understanding on whether or not the case should be settled outside court.  (This service can only be offered after all levels of the Utilization Review process have been exhausted.)

Integrated Multi-Specialty Review:

A review by a panel of at least two specialists from different fields.  Situations requiring such a review would include but are not limited to: health care services having been provided through a multi-disciplinary treatment program or health care issues crossing the scope of service of multiple disciplines.  These reviews may apply to determinations not to certify health care services, evaluations of the medical necessity of prospective health care services, or a request for a comprehensive retrospective review of health services.

ORGANIZATIONAL IMPROVEMENT

Services intended to improve the quality of your organization and the performance of its employees.

Improving Organizational Performance (IOP):

Improving Organizational Performance focusing on Quality Assurance measures, staff development programs, credentialing and privileging measures for physicians, and ongoing performance measures for nursing staff, in cooperation with the client’s Director of Nursing and Director of Quality Assurance.

URAC Training:

PRN has developed a URAC training course that includes a pre-test, URAC Standards, and a post-test.  The training may be taken online at www.cmeprogramonline.com or by mail.  This course is offered to all companies interested in outsourcing its URAC training for its employees, in efforts to maintain compliance with URAC Standards.

Certification of Reviewers:

PRN has developed “The Physician Advisor Certification and Continuing Medical Education Program,” which exemplifies the core curricular components of Utilization Reviews and comprehensively educates physicians on everything they need to know to perform medical reviews.  The course provides certification as a Physician Advisor, as well as 5 Category 1 Credit hours.  This program is a great way to ensure that your reviewers have been fully trained and is offered at a discounted rate when sponsored for all reviewers in your network.

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