Utilization Management (UM) decision-making is based solely on medical necessity, appropriateness of care and service, and existence of coverage, and that South Atlantic Medical Group, IPA does not specifically compensate practitioners or individuals conducting utilization review for issuing denials, nor does South Atlantic Medical Group, IPA offer incentives to encourage decisions that result in underutilization or denials.
Practitioners are ensured independence and impartiality in making referral decisions that will not influence the following: Hiring, Compensations, Termination, Promotion and/or any other similar matters.
Utilization Management decisions are made based on nationally recognized objective standards, criteria and guidelines that are based on sound medical evidence. Providers may contact South Atlantic Medical Group for copies of all policies and procedures as well as Clinical Criteria used in the decision making process. Providers are encouraged to discuss UM decisions with our Medical Directors. You may reach Dr. Dan Kahen, MD at 323-725-0167 to answer your questions. No physician reviewer receives financial incentives to limit, restrict or deny services.