named programs · 4 · from sources
What they call their work
Coding and DRG Validation
Audits ICD-10 coding and DRG assignments for accuracy and compliance, involving certified coders and physician specialists to validate documentation and ensure proper reimbursement.
Cost Outlier/Billing Validation
Conducts line-by-line review of itemized charges to verify services billed were ordered and provided, including medical necessity of admission and length of stay.
Independent External Appeal/Dispute Resolution Review
Resolves payment disputes between providers and payors involving medical necessity and/or DRG assignment using board-certified, conflict-free physician reviewers who reference nationally recognized medical criteria and guidelines.
Utilization Review
Reviews medical records to assess medical necessity and quality of care across all levels of service, conducted by registered nurses and board-certified physicians using nationally recognized criteria.
activities · 3 groups
What they do
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Health Information Exchange Support 2 activities
- Maintains URAC accreditation for independent review servicesOperates as an accredited Independent Review Organization (IRO) under URAC standards, maintaining External Review accreditation since achieving Comprehensive IRO accreditation in 2013. This supports credibility and compliance in delivering external appeals and medical review services.
- Operates external appeal and dispute resolution programsManages an independent external appeals process to resolve payment disputes between providers and payors related to medical necessity and DRG assignment. Services are delivered in accordance with URAC standards and leverage over 40 years of clinical and coding expertise.
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Healthcare System Administrative Support 1 activity
- Conducts medical peer review and utilization review servicesProvides utilization review services to evaluate the medical necessity, appropriateness of care, and adherence to quality standards, serving healthcare providers and payors across all care settings. This includes prospective, concurrent, and retrospective reviews supported by clinical documentation analysis.
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Uncategorized 1 activity
- Provides coding and DRG validation servicesOffers coding and Diagnosis-Related Group (DRG) validation services using certified coders and board-certified physicians in active clinical practice. Reviews include validation of ICD-10-CM, ICD-10-PCS, and DRG assignments based on client-specified Grouper versions, ensuring accuracy in billing and reimbursement.
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financials · form 990 · fy2025
revenue
Total revenue$9.75M
Contributions & grants$00%
Program service revenue$9.51M98%
Investment income$239K2%
Other revenue$3K
expenses
Total expenses$8.88M
Program expenses87%
Admin / overhead13%
Fundraising0%
Salaries & benefits$5.59M
Grants paid out$0
Largest expense lineCompensation
balance sheet
Total assets$11.49M
Cash$3.55M
Investments$4.00M
Liabilities$2.71M
Net assets$8.78M
Liquid reserves10.2 mo
6 years on record · 2020–2025 · YoY revenue -1.0%
leadership · form 990 part vii · fy2025
Who runs it
paid leadership · 14
| Name | Title | Hours/wk | Compensation |
|---|---|---|---|
| FRANCES SCOTT | EXECUTIVE VICE PRESIDENT | 35 | $274K |
| ROBERTA BOCKER | CHIEF OPERATING OFFICER - | 35 | $242K |
| ANNA M GEORGIADIS | SENIOR REGISTERED NURSE | 35 | $208K |
| TOM MCCANN | DIRECTOR OF EDUCATION | 35 | $159K |
| CHRISTOPHER TOGIAS | CONTROLLER | 35 | $140K |
| CORLISS VARNUM MD | BOARD MEMBER | 1 | $2K |
| JOSEPH MALDONADO MD | BOARD PRESIDENT | 1 | $2K |
| KIRA GERACI-CIARDULLO MD | SECRETARY | 1 | $2K |
| LIANA LEUNG MD | BOARD MEMBER | 1 | $2K |
| LOUIS AUGUSTE MD | BOARD TREASURER | 1 | $2K |
| NATALIE ADLER MD | BOARD MEMBER | 1 | $2K |
| PARAG MEHTA MD | BOARD MEMBER | 1 | $2K |
| ROBERT HUGHES MD | BOARD VICE PRESIDENT | 1 | $2K |
| RUBEN PINKHASOV MD | BOARD MEMBER | 1 | $1K |
relationships · 6
Who they work with
- NAIRO Coalition — Active member organization contributing to industry standards for medical peer review and utilization review.
- URAC Government — Accrediting body for ESMSEF as an Independent Review Organization since 2013.
- URAC Government — Accrediting body for ESMSEF as an Independent Review Organization: External
- URAC Government — Adheres to URAC standards in conducting external appeal and dispute resolution reviews.
- payors Partner — Provides utilization review and cost outlier/billing validation services to healthcare payors
- providers Partner — Provides utilization review and cost outlier/billing validation services to healthcare providers
strategies · 4
How they approach the work
Named approaches extracted from this org’s sources. Where others share an approach, follow it to see the full set of orgs running it.
- Conflict-Free Review Protocolmethodology: conflict_free_reviewBy assigning reviewers without significant conflicts of interest, the organization ensures impartiality and trust in medical review decisions because perceived and actual bias is minimized, increasing stakeholder acceptance of outcomes.
- Physician-Led, Evidence-Based Peer Reviewmethodology: physician_led_peer_reviewBy using actively practicing, board-certified physicians and evidence-based medical criteria to conduct peer reviews, the organization ensures clinical accuracy, objectivity, and real-world applicability in medical dispute resolution because clinical expertise and standardized guidelines improve the validity and trustworthiness of outcomes.
- Specialty-Aligned Clinical Reviewmethodology: specialty_aligned_reviewBy assigning board-certified physicians with aligned medical specialties to conduct reviews, the organization produces more clinically accurate and relevant evaluations because reviewer expertise directly matches case complexity and medical context.
- Standardized, Clinically-Informed Coding Reviewmethodology: clinically_informed_coding_reviewBy combining clinically active physicians and certified coders trained in national guidelines, the organization ensures technically and clinically accurate coding and DRG validation because dual expertise bridges clinical reality and billing precision.