Hierarchical condition category (HCC) ) relies on ICD-10 coding to assign risk scores to patients. HCC is becoming increasingly prevalent as the healthcare reimbursement environment shifts to value-based payment models. Along with demographic factors (such as age and gender), health plans use HCC coding to assign patients a risk adjustment factor (RAF) score. A patient’s RAF score predict costs.

SFUR has the qualifications and experience to provide Independent Review Organization (IRO) Services to health care providers Corporate Integrity Agreements (CIAs) with the Office of Inspector General of the United States Department of Health and Human Services (OIG) and the related Settlement Agreements entered into with the United States.

Medical cost ContainmentMedical Bill Negotiation Medical Bill Negotiation SFUR has successfully negotiated medical bills on behalf of payers for over 20 years. The utilization of practicing physicians typically with medical coding experience has been the single largest factor in our success with medical bill negotiation. Over 70% of the time, SFUR achieves success through this process. Our fee structure can…

Medical Cost ContainmentMedical Cost Containment Management Medical Cost Containment SFUR defines medical cost containment as the process of leveraging medical and business knowledge to potentially lower the cost of medical bills. Our results speak for themselves. Typically, if our payer customers pay a fixed fee for our services (regardless of the savings outcome), they will generate a 400% return on…

Medical Cost ContainmentReasonable Charge Analysis Reasonable Charge Analysis SFUR is routinely retained to provide a usual and customary reasonable charge review (UCR) of charges submitted by the providers. SFUR will review all bills and associated clinical documentation. SFUR will review and compare with standard coding guidelines and customary and reasonable rates according to criteria and methods. Reasonable Charges (billed charges…

Medical Cost ContainmentMedical Bill Review Medical Bill Review The competitive landscape for medical bill review is vast and large. There are no barriers of entry in the medical bill review market place. Hundreds of companies offer experienced medical bill analysts and nurse reviewers to find un-bundling of services, and non-compensable charges. These companies can use national provider networks, Usual and…

DRG Claims Service provides expertise in identifying, correcting, and obtaining verified changes to DRG coding errors. SFUR licenses a customized pre-payment DRG auditing program that flags potential problem claims that are reviewed initially by nurses and if a clinical review is required, physicians perform the full clinical chart review.

SFUR Ensures DRG Claims compliance and integrity with provider-verified audit results with a customized service model for managed care payers.

Our clinical and business leadership brings decades of experience in cost containment in every payer-based and managed care setting.

Ongoing Professional Practice Evaluation (OPPE) Peer Review is used to make final judgement about quality of care in many quality assurance activities. OPPE evaluates practitioners who have been granted privileges and to identify those a practitioner’s clinical and professional competence.

Focused Professional Practice Evaluation (FPPE)  Peer Review is used to make final judgments about quality of care in many quality assurance activities.   Focused Professional Practice Evaluation (FPPE) is the follow up process to ensure that there is sufficient information available to evaluate a practitioner’s competence.  FPPE is needed at the time of initial credentialing, as a result of the data evaluated during OPPE, and when additional data or reports indicate the need for a focused review of adverse events.

Utilization Review is the process of making sure health care services are being used appropriately, with high-quality care administered as economically as possible and in accordance with current evidence-based care guidelines.

As value-based reimbursement models become more prevalent, hospital utilization management will take on a more important role. SFUR provides prospective, concurrent, and retrospective utilization review in the provider community.