Public programs are increasingly under pressure – from rising costs of health care,
the growing number of uninsured, an aging population, the alarming prevalence of
chronic conditions, and a shrinking tax base. Administrators must carefully balance
the need to reign in program costs with ensuring that recipients are receiving necessary
and good quality care.
Whether you’re looking for prior authorization,
utilization management services, quality improvement initiatives,
appeals and medical review and care management
solutions that address the acute, chronic, and complex health care
needs of your recipients, KePRO has a portfolio of services designed to control
escalating public costs and fit your program needs. Click here
to view our services.
KePRO is also a full participant in the GSA Advantage!Program, the federal government’s
approved vendor system designed to eliminate the costs and time frames associated
with the procurement process. KePRO is listed on the Multiple-Award Schedule (MAS).
Click here to view the GSA schedule.
KePRO
Since 1985, KePRO has provided solutions for over 17 million
members. KePRO is URAC accredited in Health Utilization Management and Case Management. We
are also licensed to perform medical review in 29 states. Our public programs have included:
- Quality Improvement Organization for Medicare (CMS) provided by KePRO’s subsidiary,
Ohio KePRO
- Prior Authorization Services and Utilization Review for numerous state Medicaid
agencies
- Care management programs for TRICARE and other federal government agencies.
To learn more about how KePRO’s clinically driven, evidence based solutions can
support your population across the care continuum and reduce your health care costs,
call our Business Development professionals at 1.800.222.0771, or
email us today.
KePRO is one of the largest and most experienced federal, state, and local government
utilization review vendors in the nation. With seven Medicaid contracts in four
states and as the Ohio QIO contractor, we review over 600,000 cases per year.
Our ultimate objective is to improve the appropriate utilization of government services
in a cost-effective manner. We use our review acumen to identify methods to improve
delivery of services across the continuum of care through data analysis, provider
cooperation, quality controls, technology, and innovative approaches.
Our Solutions
KePRO performs prior authorization to determine if the services:
- Were reasonable and necessary
- Were furnished in the appropriate setting
- Had documentation to support DRG assignment
- If the services met professionally recognized standards of health care, including
the completeness, adequacy, and quality of hospital care provided
- If the services were in compliance with state and federal policies, administrative
rules, and regulations.
Our Process
KePRO’s expert staff uses clinical review criteria and protocols such as InterQual®
and Milliman; consults with physician providers as appropriate; and collects the
necessary information to make a determination for the medical necessity of the services
in question. Once medical necessity is determined, we notify the physician, the
facility rendering the service, and the patient of the approval.
When services are not deemed medically necessary, our staff forwards the case to
our medical director for review and final determination. We also have access to
a review panel of over 3,200 physicians and other health care professionals.
Any adverse determinations are based upon a physician’s review; should the medical
director determine that the services do not meet medical necessity criteria, a written
notification is sent to the patient, physician, and /or facility rendering service.
The written notification includes the reason for the determination; an offer to
provide, in writing, the clinical rationale for the determination upon request;
and our appeals process.
Upon completion of initial review, an authorization number or non-authorization
number is provided to the member, physician and the facility. Upon reaching a determination,
KePRO communicates the decision with the member, physician and facility and provides
the authorization (or non-authorization) number, verbally, or in writing, as directed
by each client.
Web Based System
KePRO employs a robust, web based system to process our reviews. Providers can input
the requests directly into our system, which conserves resources for clients and
health care providers, and leads to quicker determinations and increased customer
satisfaction. We also accept requests over the phone and by fax. All determinations
are posted online, in our HIPAA compliant, secure system.
Reports
Clients have access to online reports and real time data, available any time, day
or night. Providers have access to their own data, which they can use to benchmark
themselves against other providers.