SecureCare’s Clinical Review objective is to ensure all in-network clinics utilize an appropriate level of care for patients from a medical necessity standpoint. SecureCare does not determine the appropriateness of care by prior authorization. Instead, we provide oversight through retrospective data analysis.
A retrospective analysis of each payer’s historical claims data, combined with SecureCare’s knowledge of typical practice patterns for each profession by diagnosis, is utilized to develop clinical benchmarks. These are defined as a target for a clinic’s entire patient population by line of business, and when exceeded, initiates an in-depth medical record review. Benchmarks are not a per-patient cap, but a cumulative average of all patients seen during a 12-month period.
Clinics who remain within the set clinical benchmark may practice with minimal oversight. Clinics who exceed set clinical benchmarks are defined as outliers. Medical record reviews are performed on these clinics by licensed peers based on “Best Practice Standards” to confirm outlier status and develop recommendations for the clinic to become compliant.
Each month, SecureCare posts report cards in the Provider Portal. Report cards display key performance metrics for each clinic and provider as well as a comparison to the clinical benchmark(s) and your peers in the network.
Credentialing is a critical function allowing SecureCare to properly identify qualified providers to participate in our network. It ensures providers fully meet all established industry standards. Since being URAC accredited in 2012, SecureCare has credentialed thousands of conservative care providers.