Forté’s utilization review process identifies and stops over-utilization. We work with the treating physician in the review process to assure objective decisions that take into consideration the individual aspects of each case. Our strong, URAC accredited utilization review program ensures the injured worker receives care that is appropriate, cost-effective and medically necessary. We provide:
- Quality review decisions using nationally-accepted evidence-based medical guidelines
- Strong physician involvement in the review process
- Customized services
- Timely decisions
- National experience
Pre-Authorization / Pre-Certification Review
Our clinical staff of nurses and physicians provides effective reviews of proposed treatment, using evidence-based medical treatment guidelines in the process. Forté’s experienced utilization review nurses coordinate and review requests for treatment and obtain physician reviews on any treatment not meeting the specified guidelines. Peer-to-peer conversations are offered to the requesting physician whenever there is a potential for a denial of all or part of the requested services. This allows for open communication between the reviewer and the requestor, assuring a complete review process.
Physician Peer Review
Forté offers a comprehensive peer review process to assist in addressing broad areas of medical necessity and causal relatedness. This review is useful in halting unproductive or unrelated treatment.
All reviews are sent to physicians in the same or similar specialty. Review physicians address specific questions posed by the submitter, providing valuable information regarding the necessity and relatedness of the treatment. Forté utilizes evidence-based medical guidelines in the review process, citing the specific guidelines used in each review. An appeal process allows the treating physician the opportunity to provide additional information or justification for the treatment.
Forté’s panel of review physicians consists of both staff physicians and contract physicians in active practice. Our panel covers numerous specialties and includes physicians licensed in many states. All review physicians are board-certified in their respective specialties. Forté adheres to the jurisdictional requirements that apply to services provided in various states, including issues of licensure and use of the appropriate review guidelines.