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Medical Case Review

HSAG provides medical case reviews for public and private clients throughout the United States. This includes medical reviews for Medicaid agencies, private and managed care plans, hospitals, and outpatient surgery facilities. Staff members have conducted over 1 million medical record reviews since HSAG began this activity 40 years ago. With this experience, HSAG has honed its expertise in all types of case review, implemented processes to efficiently handle large volumes of reviews, and developed an infrastructure to accommodate multiple states and geographical areas while incorporating local input. HSAG has extensive experience in performing electronic health record reviews remotely, as well as managing paper health records.  HSAG has an excellent performance record, exceeding CMS and other project metrics for timeliness and satisfaction.  HSAG is a NCQA-licensed Compliance Auditor (National Committee on Quality Assurance)

HSAG has a panel of 300 physician reviewers across multiple medical, surgical and professional specialties. Our review panel also includes non-physician peer reviewers such as nurse practitioners, psychologists, pharmacists, dentists, and registered nurses. HSAG has experience in quality reviews (899,000), utilization reviews (300,000), billing and/or payment reviews, and documentation reviews. It can offer expeditious clinical peer review, timely and effective two-way communication with local clinical leadership, identification of system issues that impact patient outcomes, and utilization of appropriate tools, forms, and processes that facilitate discussion. Based on extensive QIO (Quality Improvement Organization) experience, HSAG offers expertise in not only the review of information regarding quality of care but the ability to identify processes and tools to address the quality of care issues that are identified. HSAG can provide feedback on individual cases to assist clients in identifying opportunities to improve care, as well as improve the internal processes to prevent a recurrence.


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Utilization Management

For more than 40 years, HSAG has been performing utilization review of health services to ensure that patients receive optimal medical care that is medically necessary and delivered in the appropriate setting. HSAG has extensive utilization management experience, having reviewed more than 300,000 medical and surgical cases for medical necessity and appropriate level of care.  Clients include self-funded health plans and state agencies. 

HSAG uses national evidence-based guidelines for prospective, concurrent, and retrospective reviews.  These guidelines support clinical decision making, ensuring that the right care is delivered by the right provider, at the right time and in the right place.  The first level reviews by Registered Nurses promote an efficient process to facilitate timely and appropriate care and treatment. More than 300 Board-Certified Physician Advisors are available to assist in determining medical necessity if the requests do not meet the criteria. HSAG offers reconsideration, second opinion, peer-to-peer discussions and appeals reviews for services that have been determined not medically necessary.  A full range of reporting options is available as determined by the client’s need.

External Quality Review and Peer Review

HSAG performs external quality and peer review for health care facilities, health plans, health care corporations, and state and federal agencies.  When internal peer review is not available due to conflicts of interest, lack of medical staff with the clinical expertise required, or conflicting opinions, HSAG can provide an external peer review to monitor medical staff performance.   Performance issues may negatively impact a client’s reputation, accreditation, patient care quality, and may open an opportunity for legal risk.  HSAG has over 300 board-certified physician reviewers who can provide their clinical expertise to identify quality of care issues and other performance improvement opportunities. Case reviews are matched to physicians in the appropriate specialty/subspecialty. Upon request, HSAG and its roster of health care providers will assist in the development of a quality improvement plan for the client. 

Behavioral Health Reviews

HSAG has expertise in providing behavioral health reviews, including substance abuse prevention and treatment services.  HSAG’s Medical Review staff have performed behavioral health reviews for multiple state agencies and facilities.  Reviews are conducted for determination of appropriate services and treatment as well as identification of quality of care issues.  HSAG’s panel of physician reviewers includes adult and child psychiatrists and addiction specialists.

Quality Improvement Plan (QIP) Development

When a quality of care issue is identified, HSAG utilizes its 40 years of experience as a CMS Quality Improvement Organization (QIO) to assist in the development of a quality improvement plan. HSAG’s nursing staff and HSAG’s Chief Medical Officer, in conjunction with the board-certified Physician Advisor assigned to the case, can assist the client with the development of a QIP based on the severity of the outcome, the standard of care, educational needs that were identified, etc.  Based on the client’s requirements, HSAG offers a wide range of assistance including the peer reviewer’s suggestions for improvement, policy and procedure revisions, and staff and physician retraining.  Root cause analysis (RCA) can be conducted to determine causation.  The goal is to prevent recurrence by developing an appropriate quality improvement plan (QIP) based on causation and nationally recognized standards of care related to the treatment or service under review. If measurable outcomes are needed, HSAG will assist the client in determining what follow-up monitoring is indicated, and how to sustain improvement over time.

For more information, please contact 602.801.6922.