utilization review

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University of Cincinnati, Main Campus *

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4008

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Health Science

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Feb 20, 2024

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docx

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1 The Utilization Review Process Courtney C. Miller Health Information Systems, University of Cincinnati – Clermont HCMT 2025: Advanced Coding Applications Professor Erin Morrow January 28, 2024

2 The process of utilization review or what is often referred to as utilization management is a crucial pillar in all the various types of healthcare organizations and its purpose is to determine the medical necessity of patient treatment and services. There are several types of utilization review that all impact reimbursement and include: prior authorizations, concurrent reviews, and retrospective reviews (Giardino & Wadhwa, 2021). The different types of utilization reviews take place at different points in a patient’s treatment. Prior authorization, or a more frequently used term “prior auth”, takes place before any treatment is rendered. Prior authorization is used to determine the medical necessity for treatment that is being ordered for a patient. The process involves a physician filling out appropriate paperwork to show the need for services along with providing information to support the need. Prior authorizations aid in ensuring appropriate spending by way of not performing unnecessary tests or procedures and can also lead to more beneficial treatments or services. Next, concurrent reviews are completed while a patient is actively receiving medical care in a facility. Concurrent reviews ensure that patients are receiving efficient and effective care while reducing the number of unnecessary treatments or services. They are completed by overseeing the details of a patient’s treatment while they are undergoing it and allow for evaluation to determine if a patient is a candidate for additional services such as case management. Lastly, retrospective reviews are completed after a patient is discharged from a facility. According to Mirra Healthcare (2023), the best practices for a successful utilization review process include: clearly defining authorizations, procedures, and duties, assigning well-trained and versed physicians to advise the review process, continuous concurrent case review, and always focusing on improving areas of clinical documentation. Utilization review processes must be clear and concise so that each team member is comfortable with the responsibilities assigned to them to complete a review. This, in turn, increases accuracy which leads to less error in reimbursement. Having multiple Physician Advisors is beneficial in the utilization review process as they can look at cases from not just a clinical

3 perspective but a legal perspective as well which impacts reimbursement. Running reviews on current patient cases can eliminate unnecessary tests and procedures and allows for appropriate documentation to support the necessity of those services that were rendered which directly affects reimbursement. Lastly, the importance of documentation review is paramount when discussing utilization review as documentation is what ultimately supports the need for or the denial of a service being rendered. Having documentation review methods in place will decrease claim denials. Anyone who has worked in healthcare is most likely able to attest to the statement that utilization review can lead to resentment between patients, physicians, and insurance companies (Team, 2022). An example would be if an insurance company denies a claim, the patient is then responsible for covering all costs and often cannot afford to do so. Another area for potential conflict is if a patient needs an experimental procedure to rule out a diagnosis as these are often not covered by insurance companies and may lead to a more in-depth utilization review process to obtain coverage. Lastly, staff often have a negative reaction to having to complete any type of utilization review as it can be time- consuming and add additional stress. Without an effective utilization review process in place, healthcare organizations could potentially face significant financial loss and a decrease in patient care. Should a healthcare facility not have a strong utilization review process in place, the potential for demise in revenue exists along with quality patient care (Watson, 2018). The cost of healthcare services is significant and utilization review processes ensure that those costs aren’t wasted for both the provider and the patient. Utilization review processes that are effective result in reduced costs for patients, higher reimbursement for organizations, and overall patient care that is more effective.

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