Utilization Review and Coding Validation

IPRO has extensive experience providing services that ensure that care rendered to patients is appropriate, necessary, and meets professionally recognized standards of care.

  • Medical record review is performed by an interdisciplinary team of health information management professionals, registered nurses and board-certified, actively practicing physicians.
  • IPRO staff are highly skilled in managing large amounts of confidential data, including coordinating with information systems vendors and interacting with health care providers.
  • Our reviewers conduct line-by-line and cost outlier bill audits, determinations of medical necessity and reviews of DRG assignments, and are experienced in identifying quality problems and fraud.
  • Our data analysis department, composed of programmers, statisticians and epidemiologists, conducts profiling and pattern analysis of claims data.
  • IPRO has improved upon standard monitoring approaches by creating specialty practice norms, analyzing medical claims and utilization data, and developing software technologies, review criteria, and statistically based clinical research projects.
  • IPRO has extensive experience conducting complex, large scale DRG validation and retrospective review programs and employs a proactive approach to cost containment with a successful record of cost savings.

As New York State’s Medicaid Utilization Review and Quality Assurance Agent, IPRO currently has responsibility for over 160,000 concurrent and retrospective utilization reviews annually. These reviews include DRG/coding validation and analysis, quality of care assessment, and data profiling and analysis.

As the AIMS/AIDS Contractor for the State of New York, IPRO conducts reviews of utilization and quality of care provided to persons with HIV in acute, ambulatory and chronic care facilities.

IPRO also performs individual case reviews to fulfill state and/or federal mandatory review requirements including independent external reviews of appeals of managed care determinations and Pre-Admission Screening and Resident Reviews (PASARR) of patients with a psychiatric history who are being admitted to a nursing home. In addition, IPRO conducts survey and certification activities.

With more than 20 years’ experience conducting retrospective review and other cost containment programs, IPRO can provide state agencies with the expertise and tools to ensure successful implementation of utilization review.