Provider Resources, Inc. (PRI) Services
Medical Peer Review Services
PRI offers full fledged Peer Review services. PRI has two Board Certified Physicians, serving as Medical Director and Assistant Medical Director. Two Medical Directors ensure that there will always be mission critical coverage and a second opinion. In addition to being supported by nursing staff, each has the ability to call-in Board Certified specialty providers that will provide medical review and panel services in a peer to peer fashion. Dr. Dennis E. Agostini, Ph.D., D.O., FACEP, has over 25 years of Medical Review experience and through his university affiliations he routinely interfaces with over 100 hospitals, physician offices and clinics with regard to 5 internships and 13 residency programs. Dr. Christopher Ewing, MD, FACEP, has over 10 years experience in Emergency Medicine planning and practice. Recently, Dr. Ewing was instrumental in the review of the Continuity of Care Document (CCD) and Summary Medical Document exchanged from area to area throughout multiple EMR systems through the Nationwide Health Information Network Trial Implementation project sponsored by the Department of Health & Human Services. The assessment will include review of documents for clinical effectiveness and appropriate standards of care. Input is also required regarding appropriate policy changes.
Fraud, Waste & Abuse: Investigative Services
Under the direction of William McBee, PI, CFE, who is also PRI’s Chief Compliance Officer, our Investigative Services staff is highly capable in the areas of fraud, waste & abuse, inclusive of specialized healthcare fraud issues such as improper medical billings and payments. Our staff will provide timely and thorough complaint investigation, well-founded resolution of complex fraud issues, and experience-based assessments regarding civil & criminal prosecution risk or potential. As a former senior special agent of the OIG, USTVA, government official, and TBI special agent/criminal investigator, Mr. McBee brings a unique combination of education and experience to bear against a broad range of issues. By combining our dedication to compliance measures with staff experience in the areas of issues tracking, statistical data analysis, and problem resolution, our Investigative Services team can ensure accurate research, in-depth analyses, and legally-founded results. As a regular and experienced presenter at HBMA’s Compliance Course, Mr. McBee and our Investigative Services team has demonstrated the ability to provide educational assistance to clients, both large and small, who may require professional training and feedback in areas of critical risk.
Regulatory and Policy Analysis and Development
PRI’s knowledge of HHS programs is broad based and covers a variety of areas from Office of Inspector General (OIG) on the HHS and Office of the Secretary level to sub-agencies such as the Centers for Medicare and Medicaid (CMS). PRI professionals have the knowledge, skills, and ability to guide and help others understand healthcare policies, provide critical analysis, and assist in program development, from source material such as the basic legislation to application of the final rules. For example, policies may include provisions from the Medicare Modernization Act (MMA) of 1996, Balanced Budget Amendments (BBA) 1997 and 1999, and the Medicare Reform Act of 2003 that includes the Medicare pharmaceutical benefit. In addition, our experts have specialties that cover claims coding regulations, medical review, and quality assurance. Other expertise covers the Federal Managers Financial Integrity Act (FMFIA) and Government Auditing Standards (GAS).
Coding Audits & Chart Review
Exemplified through our work with HBMA, PRI has over 20 years of experience in coding and auditing medical claims including medical and benefit review. The staff includes clinical personnel (Board Certified physicians and nurses) with chart review experience, and certified coders with the ability to ensure standard coding for every type of claim. Of course, the team is experienced in diagnosis coding including ICD9 and ICD10, procedural coding including HCPCS, CPT4, and CDT (dental codes), and perspective payment coding such as DRG, RCC, APC, and NDC coding. PRI personnel are also equipped to provide professional services regarding National Correct Coding Initiatives (NCCS), correct coding and billing requirements, and HHPPS pricer and grouper information. This skill is also extended to other coding schemes used such as those produced by the Medicare outpatient code editor (OCE), therapy providers (such as Skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and home health agencies (HHAs) billing. Our experienced personnel are also deeply knowledgeable regarding claim exception codes used to explain denials, and partial payments.
Healthcare Compliance Education, Training & Consulting:
The PRI team has extensive experience in providing Healthcare Compliance Services including Education, Training and Consulting. PRI specialties include compliance investigation of issues, auditing, and issue tracking related to compliance/complaint/and issues. Our educational and training services in include the areas of
- Policies and Procedures related to the collection, use or disclosure of protected health information (PHI and E-PHI)
- Designations of organizations and persons with responsibilities for HIPAA compliance (e.g. the Privacy Officer, Security Officers et al)
- Record transactions of how patient requests for health record access, and
- Amendments/corrections, disclosure accounting, additional protections and confidential communications
In addition, PRI understands Medicare and Medicaid compliance requirements.