Our approach to Utilization Review ensures that injured workers receive care that is timely, appropriate, cost-effective and medically necessary.
This approach makes our review program one of the country’s most effective, and ensures objective review decisions that take into consideration the individual aspects of each case.
Our managed care subsidiary solution holds URAC accreditation, which validates the quality utilization review services we have long provided.
- We review decisions for quality, using evidence-based guidelines for every case.
- We employ strong physician involvement in the review process.
- National presence means we have national experience for better compliance.
- Our experienced case managers are able to make timely decisions for the best outcome.
- Customized service means one size does not fit all; our solutions are made to best fit the needs of each case.
Our experienced team of utilization review nurses and physicians use evidence-based medical treatment guidelines and obtain physician reviews on any treatment not meeting the specified guidelines. Peer-to-peer conversations are offered to the requesting physician whenever there is a potential for a denial of all or part of the requested services to ensuring a complete review process and the most appropriate decision. This approach significantly reduces the number of appeals and, when our decision are appealed,,the percentage of decisions overturned.
Physician Peer Review
York offers a comprehensive peer review process to ensure there is a comprehensive assessment of medical necessity and causal relatedness. Our approach allows us to prevent or quickly halt unproductive or unrelated treatment.
All reviews are sent to physicians in the same or similar specialty. An appeal process allows the treating physician the opportunity to provide additional information or justification for the treatment. Additionally, York adheres to the jurisdictional requirements that apply to services provided in various states, including issues of licensure and use of the appropriate review guidelines.