What is a Utilization Review and Who Performs Them?

What is a Utilization Review and Who Performs Them?

Utilization review is a key process in healthcare. It checks if medical treatments are needed and fit with the patient’s health plan. Nurses or doctors often do this work, making sure care is both necessary and covered by insurance.

This helps hospitals use resources well and aids patients in getting their claims approved. To ensure quality, education on utilization review becomes vital for those performing these evaluations.

Strategic Importance of Utilization Review

Utilization Review plays a pivotal role in healthcare. It involves checks before, during, and after medical treatment. To ensure that patients receive necessary care without unnecessary procedures that waste resources.

Prior authorization happens before care begins, ensuring certain treatments are covered by insurance plans. During a patient’s hospital stay, concurrent review assesses the need for continued hospitalization or specific services like MRIs. This scrutiny helps to avoid wasteful practices such as routine tests lacking clear benefits.

The Utilization Review Process

In utilization review, nurses or other medical professionals check patient cases. They look into medical records and talk with both patients and care providers. Their job includes making sure that the treatment plan fits well-known guidelines for certain health issues.

This task is key for hospitals to get Medicare and Medicaid money. There are different times when this can happen: before, during, or after a patient gets care.

For example, they might need to agree that surgery is needed before it happens. While a person is getting treated, checks ensure their care meets high standards without needing changes unless necessary. Aftercare reviews help set rules on how best to treat conditions in future cases, too.

To start working in this field requires being a registered nurse with experience, particularly in handling surgical patients, since detailed knowledge of clinical aspects becomes crucial here.

Key Players in Utilization Review

Utilization review teams, led by registered nurses, play a pivotal role in healthcare. They ensure patients receive necessary and appropriate care at the right levels across all care settings. UR experts use evidence-based MCG care guidelines to assess each patient’s clinical needs against planned interventions or treatments.

The rise in healthcare costs post-1960s spurred the development of utilization review as a tactic to prevent resource overuse and waste within hospitals initially. Over time, this approach expanded beyond acute hospital settings into health insurance companies focusing on medical necessity, misuse identification, and length of hospital stay control.

Requiring hospitals to certify admissions upfront for reimbursement considerations under Medicare/Medicaid programs introduced during Lyndon B. Johnson’s era ensured financial sustainability without compromising quality.

Financial and Operational Impacts of Utilization Review

Utilization review shapes how hospitals use money and run day-to-day. It checks if care is needed, proper, and not too costly before it’s given.

Reports show that this process can cut spending on medical services by up to 20%. On the operations side, hospitals have become more efficient as they focus only on necessary treatments, which speeds up patient flow. Thus, better resource management leads to improved service quality without raising expenses.

Utilization reviews are checks on health care to make sure it’s needed and right for the patient. Doctors or nurses with deep knowledge often do these reviews. They look at medical facts, what the patient needs, and rules of care.

This helps keep treatment safe, useful, and fair in cost. For groups like Brundage Group that focus on this task, their goal is clear: ensure patients get proper care without unneeded steps or costs.

David Lockhart