Concurrent utilization review takes place while a patient is receiving healthcare services. These services can be inpatient, outpatient, for rental of durable medical equipment, continuing use of medications and treatments, mental health services, and other specialized healthcare.  The goal of the review is to ensure that the patient continues to receive reasonable, appropriate care in the right health care setting to meet his/her healthcare needs.

Data collected during this review includes information about the patient’s continuing health status and the current treatment plan. In the event additional information is needed, the utilization review coordinator or physician reviewer may contact the patient’s attending physician to discuss the patient’s status and care. All information collected is reviewed against established utilization review guidelines or criteria, that may be nationally recognized or approved by the medical staff of the managed care organization. A decision is then made to approve or not approve services requested. In the event continuing services are not approved, a physician is involved in making the decision according to national standards because a denial or non-certification of services can only be determined by a physician.  A nurse or social worker can only approve care, and does  not non-certify a request for service, but must refer any case that does not meet clinical criteria to the physician for review.  The attending physician/other provider, facility and patient are informed of the decision in a timely manner, and each has the right to an appeal.

Voluntary accreditation in utilization management is a process that ensures that managed care companies have processes in place to ensure a fair process for persons involved, i.e. the patient, the attending physician, the facility. Healthcare organizations that are accredited by URAC, have the responsibility to conduct utilization review in accordance with URAC standards.

Aspects of the URAC requirements include ensuring licensed personnel conduct the review and that notification of the decision occurs in a timely manner.

How does utilization review differ from case management?  In either case, nurses assess patient needs and find solutions to various health care-related issues.  While the focus of utilization review is on discharge planning, the focus of a case manager may include more complex problem solving and finding healthcare resources to meet the patient’s continuing needs in the community or other setting.  Utilization review nurses assess patients and if needed, refer cases for review to physicians.  Along the way, they also provide explanation of length of stay requirements; establish criteria necessary for the level of care, and other information.  Both utilization review nurses and case managers attend multi-disciplinary meetings, and coordinate patient care and treatment with the hospital staff.

Nurses experienced in utilization review who may be seeking a job change can view our  nurse job bulletin, which offers a variety of employment opportunities across the country.  If you are interested in utilization review as a career choice, some requirements include the ability to work with minimal supervision, work independently, ability to use sound judgement and be familiar with medical terminologies, medical conditions, and medications.   Knowledge of insurance policy language, alternate resources, and knowledge of criteria for decision-making is a must, in order to assist in finding cost-saving ways without compromising quality of patient health care resources.

Physical status is evaluated against the criteria and a determination made as to whether or not a patient requires care at a particular level of service, i.e. hospital, in-patient rehabilitation, etc. The criteria used are usually developed by physicians, a review of current evidence and national guidelines published by specialty organizations.

There are levels in the utilization review process. The first level is the initial screening and review of health status and requested service by a licensed healthcare professional, usually a registered nurse or license social worker (outpatient therapy).  If there is any question regarding the need for services, the review is passed on to a physician, who holds active state licensure. That physician will review all available information, i.e. progress notes, admission history, lab data, x-rays, etc., and assess the appropriateness of the care.  If the physician determines that the care needs do not require the health services being received, he or she will sometimes discuss the care with the attending physician and determine an agreed upon treatment plan.  In some cases, there is not agreement between the attending physician and the reviewing physician and a “non-certification” notice is recommended.  With the non-certification notice, instruction is provided as to the opportunity for continued dialogue with your attending physician or how you can appeal the non-certification recommendation.

If the patient or the attending physician disagrees with the non-certification recommendation, there is a right to appeal, either telephonically or by letter to the insurance company making the recommendation.  An appeal can be “expedited”, requested immediately, or requested within a specific time period from the time of the notification.  On appeal, a specialty physician who is board-certified in the same area of practice as the attending physician will review all information, and make a recommendation to uphold or overturn the original recommendation.  In the event the appeal is not overturned, either on an expedited review or later, and the patient is still not satisfied, there may be additional appeal rights, depending on the state.

A nurse in utilization review assesses information, provides clinical information to others involved as needed and refers cases for review to physician peers in the event of any questions regarding medical necessity.