Utilization Review / Quality Assurance

Clinical Consulting Services – Utilization Review/QA

Our Utilization Review/Quality Assurance (UR/QA) department is directed by a Registered Nurse with over 22 years nursing experience and over 10 years of Utilization Review/Quality Assurance experience in the physician office. Our UR/QA department maintains a proven track record of maximizing payer incentives with a vast knowledge in all insurance quality programs, proper reporting of core measures, as well as proficient performance for federal programs including MIPS and ACO’s.

We can provide our clients with chart reviews relating to proper documentation of E&M visits, Annual Wellness Visits, Transition of Care Visits and correct quality codes regarding all preventive screenings and chronic care management required in patient care encounters. Education of current standards for documentation in the patient record can also be provided for both staff and physicians when applicable.

Our UR/QA department can also work with your office staff on standards of care, clinical office flow, clinical documentation and communication, as well as competency of clinical skills. We also strive to assist you in improving clinical inefficiencies for the benefit of your patients’ safety, health and well-being. We have a variety of approaches that will enhance the current workflow to increase staff productivity, prepare for the patient visit, and ensure that staff are maintaining communication efficiently and effectively with the patients and provider regarding tests, referrals, and authorizations.


We will assist you in accessing payer reports and reach out to your local insurance representatives to begin working current outstanding gaps in care for all insurances and increasing your quality scores within those programs.
UR/QA will work with your staff to provide education on all programs you can participate in and what pieces are necessary for proper workflow to assist with capturing all data during patient encounters. We can also assist you in monitoring that progress throughout the measurement year. All staff and providers should become an integral part of the quality outcomes in your office.
We can help you look for current pitfalls in your daily practice, current charting and billing practices, as well as ensuring you have the correct quality codes being submitted to your payers. We can work with your office staff to support your efforts in these programs.
Our department can provide you with many tools to ensure you are documenting all elements needed for proper reimbursement of the patient encounter. Our department can also provide record reviews for those visits to ensure all required documentation is included by staff as well as providers.
The UR/QA Department can provide your clinical staff with clinical competency manuals to ensure the basic skills are met by newly hired staff as well as seasoned staff.
Currently, the shift in healthcare is completely focused on quality and payment for quality services. We can help you and your staff understand the essential functions of implementing quality improvement which is necessary to increasing efficiency in the office as well as focusing on patient safety and clinical outcomes of your patients. Improving quality of care within your office will be a benefit to your patients and staff.
There are several ways we can help you build and establish some basic quality cornerstones in your daily office practice:
  • Establishing a culture of quality in your office.  We can assist you in identifying policies and procedures in your office that will enhance and promote quality efforts as well as ensuring that your staff is operating as a team dedicated to improving the care of your patients and promoting proactive activities with every patient encounter.
  • Prioritize opportunities for improvement.  We can assist you in examining your patient population and determine what quality measures are being focused on within your encounters for the most common conditions in your practice.  
  • Understanding measures.  We can provide education on measures developed from HEDIS and ensure you and your staff become better acquainted on how and when to use them.
  • Goals.  We can help you identify and set measurable goals and monitor those goals for quality within your practice.
  • Commitment to ongoing quality evaluation.  Quality improvement is a never-ending process.  We will help you monitor your quality improvement processes and ensure communication by offering transparency to you and your staff when communicating results, addressing actions that need to be taken to improve, and revising workflow to gain the desired results.