Medical Management


Medical Management

Concurrent Review

Concurrent Review of continued stay for inpatient care on a daily basis after admission monitored by Sterling MM nursing staff.

Claims Review

Claims Review of medical and hospital claims to determine medical necessity as well as proper coding of procedures and services.

Claims Audit

Claims Audit of claims prior to payment to avoid over payment, or post-payment recovery. All transactions are electronic and turn-around time can be done in 1 business day.

Case Management

Determine if there is need for case management services and initiate case management where necessary.


Pre-Certification by a phone call, fax, or secure online portal. Pre-certification review and approval for elective hospitalizations. The program relies upon standardized criteria to conduct review, for inpatient care and medical policies and clinical guidelines for use in both inpatient and outpatient services.

Retrospective Review

Retrospective Review of all cases that were not pre-authorized in a timely fashion, including emergency admissions.

Plan Design Consultation

Plan Design Consultation by experienced medical staff for insurance companies and self-insured welfare funds. Sterling MM staff help determine medical necessity to cover or not to cover services and also help determine appropriate fees for procedure codes. Outpatient services review for a specific list of outpatient services as determined by the insurer. Medical review and analysis of services.

Discharge Planning

Discharge Planning is coordinated along with the discharge coordinator of the hospital and the patient or family for care after discharge.