Why utilization review

After you've handed over all the requested information, the insurance company must respond to your appeal within a set time frame. For expedited appeals, you should receive a decision within two business days. With a standard appeal, the decision should be issued within 60 days. These time frames can prove extremely important -- if your plan does not respond within the set time line, the initial denial of coverage is automatically reversed and your insurance company must pay for the services.

So be sure to keep track of what you sent and when you sent it. If your appeal is denied, your insurance company is required to send you a "final adverse determination" letter. This document should include the specific reasons for the denial, along with any necessary medical explanations. It should also provide information on how you can receive a copy of the insurance company's clinical review criteria.

Finally, depending on your state's laws, the letter may include information on how to make an external appeal that involves a third-party decision-maker, usually an independent review organization. Independent review organizations IROs review a number of medical topics, like workman's comp and experimental treatment reviews.

They are commonly used in utilization reviews, working as third-party mitigators between health insurance companies and patients. Health insurance companies can use IROs to establish treatment guidelines and criteria, and they can also be brought in when an appeal of an adverse utilization review has been denied.

In this role, they act as both patient advocates and as advocates for cost-effective health care, which serves in the best interest of the health insurance companies. Sign up for our Newsletter!

Mobile Newsletter banner close. Mobile Newsletter chat close. Mobile Newsletter chat dots. Mobile Newsletter chat avatar. Mobile Newsletter chat subscribe. Health Insurance. Utilization Review. Insurance companies use utilization reviews to figure out if a treatment is medically necessary for you. Photographer: Visualfield Agency: Dreamstime. Types of Utilization Reviews " ". A health insurance company, hospital or independent organization can conduct a retrospective review.

Photographer: Endostock Agency: Dreamstime. Keeping it Fair: State Standards for Reviews. Did we get all the papers in place? They have to work with admissions. A lot of people use the word siloed.

This is what they got approved with insurance. Do we have all the paperwork in place? Do we have all the information we need? With registration as well, they can help as far as coding. When the patient gets discharged, do we have the correct disposition? It should be coded that way. Another department that they work very well with is case management.

We just talked about discharge planning. Utilization managers can see that upfront. So, they can decrease the length of stay by working on discharge planning as soon as the patient comes in. We want to make sure that the patient gets discharged safely and appropriately; and then, make sure that we do get our reimbursement for that care and services provided. Quality department, the quality department focuses on the quality of care provided. They have improvement activities.

Sometimes they call it quality improvement ; sometimes, they call it quality assessment. They can work with utilization management as far as standards, protocols, policy, as far as processes involved. Another department is revenue cycle. If they work with the utilization management upfront, they can mitigate those risks. And so, it will affect coding, and it will affect the reimbursement.

So, that alone helps with decreasing the revenue loss and making sure that they get the appropriate reimbursement. Way back at the beginning, utilization management started actually with the payers and have a very narrow focus. And now they are actually out there in the open, working with hospital operations.

And some have moved towards maybe working in tangent with revenue cycle, with finance. The process helps build consensus and strengthen alignment across hospital disciplines. Most important, institutionalizing a strong UR program helps hospitals fulfill their missions as patient care providers and advocates.

A data-driven management approach to revenue cycle that empowers your staff could effect sweeping change for improved long-term financial health.

The American Hospital Association says pending regulations that would affect prior authorization should be expanded to include Medicare Advantage.

UHC had announced this week that it would evaluate claims starting July 1 to determine whether ED visits were for emergent or nonemergent events. You have [n] free articles remaining this month. Upgrade Membership. Related Content. Live Webinar Finance and Business Strategy. Live Webinar Billing and Collections. Live Webinar Patient Access. Apr 01, Although every hospital has unique challenges, major breakdowns in the UR process tend to fall into the following five areas, which are explored in detail below: Department organization and management Understanding and adoption of regulatory guidelines Clinical acumen and understanding of clinical criteria Revenue cycle integration Efficient and accurate processes Department Organization and Management In U.

Understanding and Adoption of Regulatory Guidelines Providers must ensure their documentation clearly supports services billed, and that the admission order clearly identifies the level of care. Efficient and Accurate Processes For effective UR program management, hospitals must understand the critical touch points internally across departments and externally with insurers.

About the Authors Lisa Bragg. Level of care determination identifies the most appropriate and needed level of care such as intensive or intermediate versus a medical-surgical floor level of care. System delays are assessed and monitored to identify any potentially avoidable delays in care. Applying the activities within the utilization review process, the nurse must accurately document the medical necessity and level of care based on evidenced-based criteria such as MCG.

In conclusion, although this is an overview of the utilization review technique, it is important to note the process includes other methods such as physician second level review, CMS regulatory requirements, and in some cases clinical documentation improvement. Today, utilization review is one method used to demonstrate the quality of care and protect revenue integrity. Because quality and costs are of paramount importance, utilization review nurses must possess clinical judgment and critical thinking skills to proactively mitigate overutilization and misuse of resources.

The information contained in this article concerns the MCG care guidelines in the specified edition and as of the date of publication, and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date of the article.

Daniels, S. Cesta, T.