Services You Can Trust
HQSI, an experienced leader in medical review, appeals and dispute resolution for over three decades, focuses on making the right decision the first time — every time. Our expertise is recognized by URAC and the Centers for Medicare & Medicaid Services which certified HQSI as a “QIO-like entity.”
Our independent medical review and appeal services include:
- medical necessity
- readmission/combined admissions
- place of service/level of care
- experimental/investigational
- quality of care/peer review
- coding/DRG assignment/DRG validation.
- expedited, concurrent and retrospective reviews.
We can also triage appeals to help you determine the value, and feasibility, of each case before pursuing an appeal. By also preparing the appeals for high-value, high-probability cases, we can potentially save you even more time and money.
We work with providers, payers, government agencies and other healthcare organizations to meet their short- and long-term needs.
HQSI can conduct medical reviews and appeals at any level — first, second and/or third — conflict free. We will also collaborate with you to customize a solution for your organization, drawing from our years of experience and expertise. All our services use:
- The right clinical specialists; board-certified physicians, who provide clear, concise, conflict-free, and unbiased determinations
- An intuitive, user-friendly, secure web-based portal that makes it easy to submit cases, track progress, and receive final reports
- Stringent protocols with respect to timeliness, internal quality control, and training
- HIPAA/HITECH compliance, security, and code of ethics
- Credentialed and licensed allied healthcare providers
Contact us to learn more about our independent review and appeals services.
HQSI Offers a Secure and Stress-Free Process
Health Insurance Portability and Accountability Act (HIPAA) laws and guidelines are of utmost importance within the medical and insurance industries. HQSI understands the risks that exist within these industries and realizes clients can sometimes feel overwhelmed. To minimize any concerns, HQSI’s medical review services team, compliance officer and information security department work together to ensure that our business relationships, suppliers, and any software vendors are HIPAA compliant through business associate agreements and vetting.
HQSI follows the most stringent protocols with respect to internal quality control, HIPAA/HITECH compliance, security and ethics. These include the following:
- Two factor authentication
- SSL/256 bit encryption, in transit and at rest
- Full audit trail
- Log on/off activity maintained 90 days in system and then archived
- Inactivity system time out
- All services provided in U.S.
- User access controls are set according to individuals function/role and company
Contact us to learn more about our safe, secure environment. Our IT team and compliance officer are available to discuss your needs and answer questions.
Online Access Portal
Our secure client portal uses state-of-the-art technology to manage case workflow. Clients can access our intuitive, user-friendly client portal to submit cases, upload medical records, and receive final determination reports safely and securely. Reports are also exportable, and our team is very flexible and adaptable when it comes to meeting your specific needs.
Rely On Us
Superior URAC-Accredited Independent Medical Review and Appeal Services
With over 30 years of healthcare, medical review and appeal experience, HQSI provides reliable reviews — and clearly written determinations — that clients can count on. Our services are timely, cost-effective, free from conflict of interest, and supported by our national panel of U.S.-based, board-certified physicians.
We have been continuously URAC-accredited since 2008, first as an Independent Review Organization (IRO) and then as a comprehensive IRO. By receiving URAC accreditation, HQSI has demonstrated a commitment to quality healthcare, accountability, and to meeting strict quality standards.
HQSI brings credibility, value, and a quality perspective to all its services. This focus on quality builds upon our decades as a federally designated Peer Review Organization (formerly known as PRONJ) and as the prior Quality Improvement Organization (QIO) for New Jersey (from 1982 – 2014).
We were also a state-certified IRO for New Jersey, and are certified by the Centers for Medicare & Medicaid Services as a QIO-like entity. As such, HQSI is able to perform medical reviews in New Jersey and other states.
A Proven Team for a Better Experience
HQSI’s experienced, customer-oriented team brings a unique blend of qualitative, quantitative, and historical knowledge to our medical review and appeal services. Since our founding, we have reviewed more than three million medical records and appeals for a diverse client base and designed, implemented, and evaluated hundreds of successful quality improvement projects. Our seasoned professionals deliver practical knowledge and proven solutions to today’s healthcare challenges.
HQSI’s Clinical Network
Led by our medical director, all of the physician reviewers in our network are board certified, have an active, unrestricted license to practice medicine in the US, are fully domiciled in the US, have been in active practice for at least five years in their specialty, and have privileges in at least one US hospital or healthcare facility.
Our physician reviewers cover a large group of high-demand and diverse specialty areas. We also have reviewers from some of the less common specialty areas such as interventional radiology and sleep medicine.
Effectively Manage Appeals
Medical necessity denials are often the financial stress points for healthcare organizations. Even if your organization has a small percentage of denied claims, the appeal preparation and management process can be cumbersome and an inefficient use of already limited resources. However, recouping even a small percentage of denied dollars can have a significant impact on your bottom line.
Whether your organization is undergoing a revenue cycle management assessment, re-evaluating operations, or just looking to capture every possible dollar, HQSI can work with you to reduce the administrative and financial burden. HQSI can efficiently and effectively handle your medical necessity denials and appeals – without adding to overhead costs.
HQSI’s U.S.-based network of board-certified physicians and credentialed health professionals will efficiently meet your needs, within your budget. HQSI reviewers use evidence-based criteria and current professional standards to make the right decision the first time, every time and produce a high quality-sound determination in every case.
Our physician network covers a diverse and wide range of specialties. Their decision/determinations are always clear, succinct, and valid. We use a secure, web-based system that makes it easy to submit files, track status, and access decisions/determinations at your convenience.
Our experienced staff, history as a Quality Improvement Organization, and current status as a URAC-accredited IRO and a QIO-like entity demonstrate our reliability and service commitment. With HQSI, you get a trusted partner who will maintain quality and save you time, resources and money.
Get Started
Whether you have an ongoing or just an occasional case need, we can partner with you.
Call 1-800-752-8420 for more information
Inquiry Form Download BrochureMedical Necessity or Medically Necessary is defined as treatment for a particular condition to be required and appropriate in accordance with acceptable standards of medical practice and is performed, prescribed or directed by a provider for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are consistent with standard of care in the community and/or supported by evidence based scientific literature or standards published by nationally recognized experts and organizations generally constitute Medical Necessity.
These reviews may involve complex diagnoses; progressive conditions; and terminal illnesses. The reviews require an expert opinion using an evidence-based approach related to experimental or investigational treatments. Cases are generally conducted by a single expert reviewer; however, a panel of experts may be utilized when a majority consensus is required on highly controversial therapies or procedures.
Quality of care or peer reviews are requested to evaluate the performance of an individual practitioner or institution’s clinical practice. They can address issues or patterns of care related to patient safety, medical errors, and unintended outcomes. All reviews are performed by an expert in the same or similar specialty as the treating provider.
Upon receipt of cases requested for coding/DRG validation HQSI shall perform ICD-9-CM/ICD-10-CM/ICD-10 PCS coding validation and DRG grouping using the Grouper Version(s) defined by CLIENT and/or PAYER and will render a decision based upon applicable recognized coding guidelines and the clinical documentation contained in the record provided to HQSI by CLIENT. All coding and DRG validation shall be performed by RHIA, RHIT and or CCS credentialed staff.