The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensures the patient receives appropriate care, not too much and not too little.
The UM review process can occur during different stages of patient care. A review that is conducted before a treatment plan is called a prospective review. When reviewed during the patient’s treatment, it is called concurrent review. One that occurs after a patient has received service is referred to as a retrospective review. These different types of reviews can have varying success with regards to reimbursement of claims. There is an advantage to conducting prospective utilization reviews because the service or treatment is pre-authorized by the insurer and will be very successful with regards to reimbursement. Concurrent and retrospective utilization review will require more evidence based information to validate the medical necessity of the case. It is not always easy to prove the necessity of care once the patient has been treated and gone from the facility. Therefore, many facilities attempt to gain pre-authorization from payors before a treatment plan is started to ensure successful reimbursement.
Making clinical decisions is the responsibility of the physician. However, the UR can be conducted by non-physicians following the physician’s...