The process of utilization review can start at any point along the continuum of needed services. Utilization review coordinators who maintain an active healthcare license, i.e. registered nurses or licensed social workers, conduct utilization review in hospitals, or telephonically and on-site for managed care organizations.
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.