Our tenured clinical reviewers and performance improvement experts are committed to a fair and impartial care review process that benefits both consumers and providers. As a team, we share your commitment to quality care and timely access to healthcare services.
Our tenured clinical reviewers and performance improvement experts are committed to a fair and impartial care review process that benefits both patients and physicians. As a team, we share your commitment to quality care and timely access to healthcare services.
As a URAC-accredited Independent Review Organization (IRO) and a federally designated External Quality Review Organization (EQRO), KFMC offers a range of healthcare quality review and audit services. We work with federal and state agencies and health organizations across the Midwest and nationally. We provide an independent and unbiased review of healthcare information to help states and health organizations transform their care delivery systems. Our highly skilled and credentialed professionals offer objective recommendations to ensure everyone has access to high-quality, timely care.
This national, gold standard accreditation validates how KFMC is committed to a fair and impartial medical review process that benefits both patients and physicians.
This federal designation authorizes KFMC to analyze and evaluate aggregate information on quality, timeliness, and access to the healthcare services that a managed care plan, or its contractors, furnish to Medicaid consumers.
While ultimately improving health outcomes for patients, our proven approaches in clinical care optimization and health services review help organizations achieve greater operational consistency and enhanced performance. Our audit and review services include:
At KFMC, we find and implement better ways to help health organizations perform at higher levels, which improves health outcomes for everyone. Contact us today about the services we provide as your health improvement partner.
| KDHE, Division of Public Health, Bureau of Family Health – Maternal Mortality Abstraction and Review Services | Facilitate the activities of the Kansas Maternal Mortality Review Committee (MMRC), including chart abstraction and assessment, presentation of case findings, and facilitation of discussion and the3 development of recommendations form the MMRC. |
| KDHE, Division of Health Care Finance – Third Party Review of Denied Medicaid Claims | Provide independent, third-party review determinations for Kansas Medicaid Managed Care claims that have been denied payment or denied services and the members/provider has exhausted the interal appeals process with the MCO. |
| KDHE, EQRO Kancare | Provide external quality review services to ensure access, quality and timeliness of care for KanCare member. Using the Federally mandated CMS’ EQR Protocols, KFMC conducts a review of the Managed Care Organizations and aggregate level information and validates MCO collected and submitted performance measures and performance improvement projects. |
| Individual Hospital/Health System/Practice Contracts* | Provide independent and objective quality of care reviews for standard of care cases identified and referred to KFMC by individual provider organizations (Peer Review). |
| State Insurance Departments | Provide independent review and determinations of adverse healthcare coverage decisions made by health carriers on Kansas referred by state insyrance departments. |
| KDHE, Division of Healthcare Finance – Medicaid Utilization Review | Provides utilization review, DRG validation, and quality review services for the State of Kansas, including claims review, including high-dollar (Cost and Day Outlier) claim review, and adjusted claims payment processing on behalf of the State Medicaid program. |
| Workers Compensation Utilization and Peer Review | Provide independent and objective review to evaluate hospital inpatient services, MS-DRG validation, and excessive cost on behalf of the Division of Workers Compensation. |
| OHCA, EQRO & QIO | Provide external quality review services to ensure access, quality and timeliness of care for SoonerCare members. Using the Federally mandated CMS’ EQR Protocols, KFMC conducts a review of the Managed Care Organizations and aggregate level information and validates MCO collected and submitted performance measures and performance improvement projects. KFMC will also provide utilization review, DRG validation, and quality review services for the State of Oklahoma, including claims review on behalf of the State Medicaid program. |
*KFMC is always accepting new peer review clients
Interested in learning more about participation in these project opportunities? Don’t see a current opportunity that meets your needs? KFMC offers tailored advisory and consulting services. In addition to defined hourly rates, KFMC can provide custom project or engagement-specific cost proposals.
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