News

February 2010
Health Services Advisory Group, Inc. (HSAG), Receives URAC Health Utilization Management Accreditation

Phoenix, AZ—Health Services Advisory Group, Inc. (HSAG) announced today that it has been awarded Health Utilization Management Accreditation from URAC, a Washington, D.C.-based health care accrediting organization that establishes quality standards for the health care industry. Ultimately, URAC Health Utilization Management Accreditation provides assurance to patients, providers, purchasers, regulators, and employers that the practices of the organization performing these services are fair and equitable for all parties.

"By applying for and receiving Health Utilization Management Accreditation, HSAG has demonstrated a commitment to quality health care," said Alan P. Spielman, URAC president and CEO. "Quality health care is crucial to our nation’s welfare and it is important to have organizations that are willing to measure themselves against national standards."

HSAG has functioned for over 30 years as a team of highly skilled professionals working to form one of the most successful health care quality improvement and quality review organizations in the nation. It is the mission of this team to be a positive force in health care by providing quality expertise to those who deliver care and helpful information to those who receive health care services.

Since our beginning in 1979 as a Medicare peer review organization mandated by federal law and acting in only a portion of Arizona, we have burgeoned to our present status and now serve more than 20 percent of the Medicare population nationwide as a quality improvement organization (QIO). HSAG has also become involved with Medicaid programs in more than a dozen states where we work to assure the quality, access, timeliness, and appropriateness of care for approximately 45 percent of the nation’s Medicaid recipients.

Most medical care paid for by private or public health insurance undergoes some form of administrative review to determine the appropriateness of proposed medical care. That means almost every American enrolled in a private or government-funded health benefit plan is affected by how this type of review is administered. In 1990, URAC developed the first Health Utilization Management (UM) Review Standards to ensure that organizations conducting utilization review followed a process that was clinically sound and that respected patients’ and providers’ rights while giving payers reasonable guidelines to follow. Since creating the first standards that set the bar for health utilization review, URAC has continued to create and revise the standards that have transformed the industry.

URAC standards ensure that only appropriately trained, qualified clinical personnel conduct and oversee the utilization review process, that a reasonable and timely appeals process is in place, and that medical decisions are based on valid clinical criteria. URAC Health UM Accreditation requires each organization to establish and implement a three-step process to determine if a proposed medical treatment or service is medically necessary:

Initial Clinical Review—A licensed health professional, such as a nurse, conducts this first, critical step.
Peer Clinical Review—A physician qualified to render a clinical opinion about the proposed treatment or service must perform peer clinical review.
Appeals Consideration—Patient or provider initiates the appeal, which is considered by a qualified, board-certified physician in the same specialty but is not involved in the initial review decision. The process must be expedited, if requested.

URAC, an independent, nonprofit organization, is a leader in promoting health care quality through accreditation and certification programs. URAC's standards keep pace with the rapid changes in the health care system, and provide a mark of distinction for health care organizations to demonstrate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in setting meaningful standards for the health care industry. For more information, visit www.urac.org.

For more information contact Frank Lopez at flopez@hsag.com or at 602.308.7187.