 Physician Level Peer Review
In a time of controversy about quality medical care and the decision making process, prudent health plan administrators are seeking independent and unbiased medical recommendations. The Orange County Foundation for Medical Care offers Independent Physician Level Peer Review to assist your organization with complex decisions so you can be assured that your health plan members are receiving a fair and unbiased decision making process in the delivery of their health care. This unbiased opinion will grant your organization the ability to make sound decisions to efficiently manage expenses caused by a disability, thus saving money for your organization. An added advantage of the OCFMC process is that your liability is reduced.
The Orange County Foundation for Medical Care has access to a significant number of physicians that are currently practicing medicine in a broad range of specialties. Primary Care Review includes Internal Medicine, General Practice, Family Practice, Pediatrics and Gynecology. We also offer Nurse Review and intervention along with all other Specialty Reviews.
Our physicians make recommendations on the following types of situations:
Appropriateness of the treatment plan
Possible alternatives to the treatment plan
Comparison of coding to the operative report
Efficacy of experimental treatment
Independent Appeals Review
The purpose of OCFMC’s appeals process is to provide a HIPPA compliant appeals process for group health eligibility issues, and denial of payment for claims.
It is OCFMC’s policy to act as an advisor to the group health plan by providing recommendations and opinions regarding the medical necessity of treatment and eligibility that are meant to assist the group health plan in making sole and independent judgments. The group health plan retains the right to override OCFMC’s determination process at any time. This appeals process is headed up by OCFMC staff, physician reviewers in all medical specialties including podiatry, chiropractic, and oral surgery
Examples of claims requiring a determination include, but are not limited to:
Cosmetic versus Functional Procedures
Medical Necessity
Appropriateness of Fees
Overutilization of Services
Coordination of Benefits
Student Status
Questionable Eligibility Issue
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