One of the many ways in which healthcare organizations are assessed these days is both internal and external in the form of utilization review. Internally, there are reviews done by designated staff members (who are usually nurses) who keep tabs daily on the patient care measures set forth by a hospital as tracking measures. They are reviewing the care of inpatients on any given day, trying to look for trouble spots before they become problematic. If a major event occurs within the hospital regarding patient care, an external review will need to done to help determine any disciplinary action, workflow changes or protocol alterations that might be necessary to keep it from recurring.

Utilization Review | Medical Necessity

One of the major focuses for utilization review teams is the issue of medical necessity. Because medical necessity is a topic that will often bring about the skepticism of Recovery Audit Contractors, it’s important to assess the issue on an ongoing basis to be sure that clinical decision making and documentation support one another – and would hold up against an audit.

Utilization Review | A Necessary Evil

Described often as a “necessary evil” reviewing for medical necessity is extremely important, because in the U.S. there is a major discrepancy among hospitals when it comes to treatment for certain types of patients – because of this, it’s difficult to truly standardize a treatment plan for a single condition. The reality is, one patient may be healthy enough otherwise to receive treatment on an outpatient basis- while another patient, states away, is not and if we were to assess this on a nationwide basis, those outpatient outliers would skew data away from admission.

To Admit or Not to Admit, That is the Question!

It’s never a question of does the patient need the treatment, but rather, a question of where. A diagnostic test, in some cases, can be comfortably done on an outpatient basis. In other cases, it may be necessary for the patient to be hospitalized. This can prove a painful dilemma for admitting hospitalists who are, always in the back of their mind, wondering if they’ll get dinged later, the chart being flagged for wrong setting. Of course, the only way around this is to be certain that documentation completely supports and justifies the decision to admit or not. While it might sound cliche, it’s true in the case of UR that the best offense is a good defense.

Utilization Review | Observation Stays

One of the gray areas is always 24-hour-stays or “observation” patients. These patients are an easy target for insurers because they are hovering between outpatient and inpatient, seemingly absorbing the best of both worlds while a physician decides if the patient needs inpatient care. It is prudent in these cases for the documentation to support exactly why the patient is in limbo – are they unstable? If so, why? What are their acute needs? How are they being addressed in the observation setting?

It’s never enough to just document that there are acute needs. You need to be specific.

Utilization Review | A Second Opinion

If you disagree with a reviewer’s assessment, you’re able to request another review by a different external reviewer. The use of external review can help your organization Healthcare utilization management services can assist your organization in formulating improved healthcare strategies to significantly improve operations, profit and market position.