Our program is designed to manage health care costs by prospectively monitoring the use of health care services.
From information gathering to discharge follow-up, our utilization review nurses consider the entire treatment process for medical necessity.
Utilizing evidence-based guidelines, our nurses determine medical necessity and appropriate level of care. In addition, we explore alternative levels of care and coordinate the span of care through discharge planning.
PPS Health Services performs the following on behalf of our clients:
- Channel to preferred providers
- Apply criteria
- Monitor cases
- Initiate of approval and/or denial letters
- Physician review as needed
- Document information and the review outcome
- Initiation of Case Management referrals
- Follow-up phone calls after discharge
We conduct the following reviews to ensure quality of care and service efficacy:
- Pre-admission review
- Alternate site review
- Inpatient hospital review
- Ancillary service review
- Outpatient hospital review
- Retrospective review
- Physician review
- Concurrent review