Utilization Review
Utilization review is a method that assesses, on an individual basis, the effectiveness, appropriateness, and medical necessity of the treatments, services, procedures, and facilities offered to patients. Instead of doctors, this procedure is managed by or on behalf of those who pay for medical care (insurance companies). In most cases, hospitals hire a utilization review (UR) nurse who collaborates with the UR nurse of the insurance provider to assess the requirements for approving treatments. The review establishes if a procedure is medically necessary and could suggest a different course of action (Giardino & Wadhwa, 2022).
Types of Utilization Review
An examination of a patient’s situation and suggested course of treatment is known as a prospective review. Eliminating unnecessary, useless, or redundant treatments is its primary goal. For regular and urgent referrals but not for ER admissions, a prospective evaluation is employed. The evaluation should take place either before or after admission to a facility, but never after treatment has started (Weller, 2020). Usually, a set of criteria is used to decide if a request is reasonable and when to apply the applicable national standards of care.
One goal of prospective UR in inpatient treatment is to avoid unwarranted or improper hospitalization. A typical strategy that ensures patients get the care they require is referring patients to another practitioner. The decision to refer a patient to another practitioner helps to avoid unnecessary hospitalization which in turn ensures that costs are controlled. Referring patients to another practitioner also ensures that the patient gets the health care that they require and that the care provided is of quality.
Concurrent Review
A concurrent review begins within 24-72 hours of hospital admission and takes place while the patient is receiving treatment. Tracking resource usage, monitoring patient improvement, and lowering coverage denials after treatment is finished are the key goals of the review(Weller, 2020). This review helps to lessen the exploitation of inpatient services and to promote excellent and secure patient care throughout the inpatient portion of the treatment. The review covers the following things:
- Care Coordination
- Discharge planning
- care transition
Sets of criteria are also used in the concurrent review, frequently based on national initiatives to establish standards (Giardino & Wadhwa, 2022).
When a patient with a fractured hip is hospitalized, it’s critical to determine whether convalescent care would be better provided in a skilled nursing facility or a rehabilitation facility. The decision to send the patient to a skilled nursing facility is an example of concurrent review. Skilled nursing is a level of care that must be provided by trained individuals. In such a case, discharge planning must determine if the right degree of rehabilitation services will be offered and how long the plan would cover rehabilitation treatments in a long-term care facility. The goal is to deliver seamless services at a lower cost and in the patient’s best interest.
Retrospective Review
After the course of treatment is complete, a retrospective evaluation is often conducted. Its goal is to evaluate the timing, appropriateness, and efficacy of treatments as well as the environment in which they were given. The ability to gather information on the standard of care and compliance with federal regulations is also offered by the retrospective review. Reviewers can report back data to caregivers after identifying issues and triumphs. Additionally, you may utilize this information to inform instruction and contract discussions between hospitals and insurance (Weller, 2020).
Issues with the quality of care are frequently found while examining medical records for other problems, such as medical necessity. To ensure that the health care practices involved are addressed and improved, the physician reviewer must analyze, fix, and report the severity of issues with the quality of treatment provided when a registered nurse reviewer discovers that there are some concerns in the quality. When the treatment provided does not meet quality standards, quality of care reviews give the data necessary to assist in improving practice or policy. This guarantees that patients will receive the care they require.
Role of Communication Between Stakeholders in Utilization Review
When a patient is under evaluation for inpatient care, UR nurses begin the process of reviewing the patient’s condition and prognosis. The criteria for communication and decision-making begins with the UR hospital nurse evaluating the patient and making recommendations or seeking approval. The UR hospital nurse then consults with the UR insurance nurse and if the nurses disagree, physicians meet in a peer-to-peer setting to determine a course of action. Finally, if the insurance company denies the actions, the hospital appeals the decision with their patient’s approval.
It is important to establish a set of standards for deciding how to treat patients and a way to communicate the decisions to patients and healthcare professionals. It is advisable to delegate decision-making authority to someone who has the information and experience necessary to assess whether the requested treatment is medically essential. Having a qualified reviewer examine each request guarantees that requests are only authorized when they satisfy the requirements for medical necessity, aiding in cost management and ensuring that patients receive the care they require (Rojo, 2022). This may also help to reduce disagreements among stakeholders with competing interests.
References
Giardino, A. P., & Wadhwa, R. (2022). Utilization management, StatPearls. Web.
Rojo, M. (2022). 10 utilization management best practices, CLIMB. Web.
Weller, J. (2020). Utilization management in healthcare, Smartsheet. Web.