Case Review
OFMQ has performed independent review of health services to ensure appropriateness of care since 1972.
Across all settings of care, including departments of correction, University health systems, rural critical access hospitals, Medicare and Medicaid, OFMQ’s review verifies care consistent with evidenced-based practices and clinical research.
These focused reviews survey both the healthcare setting and medical necessity, ensuring patients receive high quality, effective treatment.
Why OFMQ?
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Medical Chart Review
The original function of OFMQ was to perform medical chart review for appropriateness of care and medical necessity. This has since evolved into a quality of care focus.
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Peer Review
OFMQ performs independent and external peer reviews for rural hospitals, secondary reviews on physician practice, and credentialing while honoring HIPAA Records Release standards.
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Experience
OFMQ has clinicians and medical records professionals with more than 35 years experience in peer review. Additionally, OFMQ has experience working with Departments of Correction and University Health Systems for independent medical case review.
Review Services
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CMS Conditions of Participation and credentialing of staff privileges require annual peer review. Our peer review experts focus on clinical expertise and evidence based medicine while utilizing proven national criteria, guidelines, and standards of care to ensure your providers are satisfying clinical requirements that could potentially impact the quality of care and/or ability to appropriately bill for services.
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When physician competency issues are identified in ongoing peer review, appropriate action must be initiated. Our 40+ years’ experience as a CMS Review entity, can assist with the development of an action plan specific to your providers’ specialty that ensures an objective and compliant remediation plan is in place.
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When an evaluation of medical necessity, appropriateness of care, or efficient use of services is required or simply expertise in discharge planning, pre-certification, clinical appeals, DRG, or coding validation is needed, we can help. With over 40 years of utilization review expertise, we have the team who can provide analysis, guidance, or corrective actions for your UR needs.
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We specialize in inter-rate reliability reviews. Our experts can quickly identify variances, inconsistencies, or deficiencies within current review processes that could lead to costly mistakes.
LEARN MORE ABOUT CASE REVIEW
LEARN MORE ABOUT CASE REVIEW
The objective of a medical peer review is to investigate the medical care rendered in order to determine whether accepted standards of care have been met. The professional or personal conduct of a physician or other healthcare professional may also be investigated. If a medical peer review committee finds that a physician has departed from accepted standards, it may recommend limiting or terminating the physician's privileges at an institution. Remedial measures including education may also be recommended.
Physician peer review is most commonly done in hospitals but may also occur in other practice settings including surgical centers and large group practices. The primary purpose of peer review is to improve the quality and safety of care. Secondarily, it serves to reduce the organization’s vicarious malpractice liability and meet regulatory requirements. In the US, these include accreditation, licensure and Medicare participation. Peer review also supports the other processes that healthcare organizations have in place to assure that physicians are competent and practice within the boundaries of professionally accepted norms.
Interested in applying for Peer Review?
Check out our Peer Review recruitment letter and application below!
Case Review – KFMC
The Oklahoma Foundation for Medical Quality (OFMQ), under subcontract with KFMC Health Improvement Partners, (KFMC), is authorized by the Oklahoma Health Care Authority (OHCA) to review services provided to SoonerCare members. Reviews are performed to determine whether services are medically necessary, delivered in the most appropriate setting and meet professionally recognized standards of care. Our primary purpose is to identify areas where care can be improved and provide feedback to Providers. Peer review is an important resource in OHCA’s effort to improve quality and efficiency of care for Medicaid beneficiaries in Oklahoma.