Medicare and Medicaid Admission Review

Optum™ Executive Health Resources® (EHR) and our specially trained physician advisors help you maintain medical necessity compliance.

It is the responsibility of the hospital to demonstrate a legitimate, defensible and consistent utilization review process that governs the selection of the appropriate admission status (inpatient or outpatient with observation services). Successful compliance programs are built on rigorous processes, access to clinical information and proactive strategies. Optum can help simplify the complexity.

Hospitals across the country today often struggle with which compliance activities should be managed internally versus outsourced, as many program components require specialized skill sets that can fall outside a hospital’s core competencies.

EHR physician advisors, now a part of Optum, can help your hospital perform concurrent admission status reviews. Our experienced team has conducted more than 10 million medical necessity reviews. Our reviews are supported by EHR Logic™, our proprietary program for classifying cases into clinical groups, delivering evidence-based content to our physician advisors, and ensuring ongoing training and quality assurance of our physician advisors' recommendations.  

Not sure how to build a best-practice medical necessity compliance program? Let us help. Read more.

Changing health care rules and regulations focused on medical necessity are a continual source of confusion for hospitals and other health care providers. To stay on top of the latest news and strategies regarding medical necessity compliance and appeals management, EHR has created The Compliance Library.