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Case Review

KFMC's Case Review Program provides objective peer review and opportunities for related education. Through high quality medical review and evidence based determinations we work to improve healthcare provided to patients in our communities. Case review is made up of dedicated staff of healthcare professionals including nurses and coders. Physician consultants are available to carry out a complete and unbiased peer review of healthcare records, answering questions of appropriateness of care, quality of care, medical necessity, and coding. KFMC has 35 years of valuable experience providing peer reviews services to government and private sector clients. Our goal is to meet the needs of our customers and provide them a valuable product.

If you are a hospital, physician office, or payer looking for an outside peer review resource, please contact our Case Review Manager, Michelle Sigmund, at 800-432-0770 ext. 366. She would be happy to discuss your needs and how KFMC could help your organization.

The case review program is composed of three lines of service:

  • Independent Review Organization (IRO)
  • Independent Peer Review (IPR) and
  • Other case review services, including abstraction services.

Independent Review Organization (IRO)

  • External review is independent reviews of adverse decisions by a third-party administrator, a health insurance plan, an insurer or a health care provider acting on behalf of an insured that a proposed or delivered health care service, which would otherwise be covered under an insured's contract, is not, or was not, medically necessary or the health care treatment has been determined to be experimental or investigational.
  • Internal review is the independent review of an appeal review by an insurance issuer or group health plan or their designee (i.e., such as a third-party administrator) of an adverse benefit determination.

Independent Peer Review (IPR)

  • Independent peer review provided to hospitals, health systems, ambulatory surgery centers and other providers as they engage KFMC as a part of their internal quality improvement and quality assurance/risk management process to provide an objective, unbiased assessment of the care provided to assure standard of care is met.

Other Case Review Services

Other Case Review services are designed to meet individual client needs by request such as focused review or clinical case abstraction.