 The Orange County Foundation for Medical care applies established criteria and standards along with the expertise of local physicians to perform Prospective Review, Concurrent Review and Retrospective Review.
The OCFMC’s Utilization Management Programs and the data obtained allows plans the ability to compare utilization patterns among providers, identify areas for improvement, assess strengths and weaknesses of specific health plans and to provide data demonstration the effectiveness of programs.
Ambulatory Utilization Review
Ambulatory utilization review (outpatient procedures) is performed by medical professionals committed to the highest standards in patient care and preventing over utilization and inappropriate billing practices. Unlike many plans, our review is performed locally to maintain the standards of the medical community. Our process provides for appropriate primary and specialty physician review of care.
Committees comprised of physicians will review cases to determine any of the following:
Services billed are medically necessary and appropriate
Frequency and duration of services or treatment is appropriate
The correct procedure or service code was used in billing
Committees also make necessary medical recommendations which related to
Contract benefits
The standard billing practice in the community
Determinations of whether the quality care meets community Standards
Prior Authorization
All non-emergency inpatient admissions, and depending on the benefit design, certain outpatient procedures may require prior authorization, on or before admission of the service/procedure being rendered. OCFMC also may provide and optional prior-to service determination program for ambulatory services in cooperation with the payer. This offers patients and physicians advice on availability of benefits prior to service.
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