There is a need to have checks and balances in every organization to ensure that the very best care is always provided. Utilization reviews, in a way, help to make that happen. What is a utilization review? Why are they so important to patient care and overall practice management? These reviews provide a great deal of information and minimize the risk that a patient is receiving improper care. At RevWerx, we work closely with our clients to ensure the best possible outcome by creating utilization reviews collaboratively.
What Is Utilization Review and the Process for It?
What is utilization review? A utilization review aims to ensure – and justify – that the treatment or care a person is receiving is accurate and medically necessary. If the current treatment or procedure may not seem to be the best choice, an alternative may be suggested. This is done by the UR nurse, a person who analyzes what is occurring in a patient’s care.
Why is this necessary?
- It ensures patients receive the care best suited to their needs.
- The process helps ensure health insurance providers will cover the costs of care.
- It may be necessary for those receiving Medicare.
- Medicare itself has specific guidelines for utilization reviews that must be followed for the organization to continue receiving payment from the organization.
- Utilization reviews provide insight that may not otherwise be noted.
Understanding Utilization Reviews and UR Nurse Tasks
A UR nurse works with the provider or the insurance company to discuss what is occurring with the patient. They first discuss if the care provided is a medical necessity and if it meets medical necessity requirements. In some situations, a disagreement may occur in which the provider and the health insurance company do not believe the same type of treatment is effective. In this case, physicians will discuss the medical necessity. This is done during a peer-to-peer conference. If there are still disagreements, then there is an appeals process that is completed.
Why Having a UR Nurse Is Critical
For organizations providing care to their patients, the ultimate goal is to ensure each person receives the type and level of support they need. Treatment coverage is never guaranteed if there is no verification of benefits and the type of care being provided is verified as the ideal solution for the patient. Every situation is unique, but there will likely be questions in many practices, especially from insurance companies. That is why having a UR nurse working for you and beside you can help to ensure your practice runs smoothly and any concerns are eliminated.
Getting Support for Utilization Reviews and More
Our team at RevWerx can work closely with you to ensure you have the right information and insight to support the utilization review process and minimize any concerns that may happen. If you are currently operating without a UR nurse, it may be time to take a closer look at the services our team can offer and why this may prove critical for your organization’s long-term growth and management.
In many situations, we can provide insights and minimize risks for practices. By offering a wide range of services for mental health and substance abuse providers, we can ensure better results. Some of the services we offer include:
- Substance abuse consulting
- Billing audits and reporting
- Claims management services
- Utilization review service
- Verification of benefits and pre-authorization
- In-house billing implementation
Learn More About Our Services Today by Contacting RevWerx
Learning about utilization review is one step in improving the management of your practice. For many organizations, it is also beneficial to streamline operations and boost bottom lines with help from our team at RevWerx. Work closely with us to find out how we can help your organization see improvement. Call 833.309.0138 or reach out to us online for the support you need.