a pair discusses utilization reviews for coverageIn the fast-paced, ever-changing healthcare marketplace, hospitals and health systems must be agile enough to ensure a quality-driven and financially stable operation. Between care complexities, endless reimbursement rules, and regulation changes, utilization management in healthcare is paramount.

At RevWerx, we understand how challenging the utilization review process can be. Our team will examine your current capabilities and recommend solutions to any obstacles in your RCM healthcare cycle. One of our areas of expertise is in-house utilization reviews.

Utilization Reviews Defined

Utilization reviews are assessments and investigations of the healthcare services, treatments, and facilities performed by doctors or nurses. These reviews are used to ensure that healthcare insurance companies are not covering unnecessary or inefficient treatment, which ends up wasting money.

UR nurses speak a different language than most other bedside nurses. In all settings, to justify payment or suggest an alternative status, the hospital UR nurse and the insurance UR nurse first discuss medical necessity criteria. If there is a disagreement between the nurses about status and therefore payment, then the physicians discuss medical necessity during a scheduled peer-to-peer conference. If there is still a disagreement between the physicians, then the hospital appeals the case with the insurance company.

One of the qualities that sets our RevWerx team apart is that we employ a UR nurse on staff. Our UR nurse becomes your advocate when dealing with insurance companies, which is an asset that makes RevWerx a distinctive leader in the healthcare RCM industry. One of the advantages of having a UR nurse on your team is that they are well-versed in the language of insurance providers.

The Effect of Utilization Reviews

With the impact utilization management has on the financial health of the hospital, it is important that collaboration exists between the utilization management department and the revenue cycle or finance department. Today’s revenue cycle teams have access to data and information technology that can assist utilization management to manage the length of stay, appropriately allocate resources, prevent denials and ensure accurate documentation for coding and appeals.

Originally, utilization management in healthcare started with a narrow focus. Now that utilization management department activities increasingly influence reimbursement and affect revenue, there is a move towards re-organizing or realigning utilization management to the finance function. Whether it be a solid or dotted line to finance, these teams must work together to ensure the financial health of their institutions.

Utilization Review Best Practices

Our RevWerx team will teach your staff utilization review best practices, including:

  • Define processes – A clearly outlined utilization review plan that defines each person’s responsibilities and authorities can go a long way in ensuring sustainability. Process documentation that includes guidelines for admissions, professional services, and care setting reviews is another step in the right direction.
  • Run concurrent reviews for all cases – For all admitted patients, it is essential to run concurrent reviews as part of their care management plan. Consistent reviews will lead to the creation of backup documentation supporting all the services rendered. Paperwork of this kind makes it easier for you to appeal rejections and retrieve denied payments by proving medical necessity.
  • Improve clinical documentation – While analyzing the results of utilization review, it is critical to spot clinical documentation errors and work out strategies that can prevent similar mistakes in the future. Such an approach is beneficial in easing the job of utilization reviewers and payers and cutting down the chances of denial of claims.

Let Our Team Guide You Through Utilization Reviews

Perhaps your organization is struggling with utilization reviews, RevWerx is ready to help. Our team is well-versed in each step of the healthcare billing process, especially with in-house utilization reviews. If you are interested in simplifying your RCM process so that you can provide treatment for more patients, reach out to RevWerx today. Contact our team by calling (800) 851-7093 or completing our secure online form for more information.