Provider Utilization Review: Helping providers pre-empt denials
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While utilization review (UR) is most often used by payers to make decisions on how to optimize patient spend against health benefits, it’s also common for hospitals to proactively review patient utilization of services and procedures across the board.
Because taking care of patients is very expensive, and hospitals front the cost—hoping that payers won’t deny claims they send in—hospitals take extra care to make sure patient spend is effective and in line with evidence-based care.
How Utilization Review Works
There are multiple entry points to the UR workflow, including:
Admission status reviews, which determine whether a patient should be admitted on inpatient status or observational status
Escalation of care, which assesses the necessity of transfer to higher levels of care like the ICU
Extended stay reviews, which evaluate whether an extended stay is justified based on patient progress and clinical needs
Pre-authorization for complex and expensive treatments
Each of these decisions is critical to get right, not only from the patient care perspective, but from a reimbursement perspective as well. Typically, physicians make urgent decisions here at the point-of-care, such as admission status from the ED or escalation of care for very sick patients.
Breaking Down the Utilization Review Market
While the physician makes the decision quickly, there is a concurrent review process that occurs while the patient is still under care, which helps confirm that decision and assess the validity of treatment during the hospital stay.
During this concurrent UR process, a specialized nurse reviews all available clinical documentation, including physician notes, test results, and orders, to confirm that the patient meets criteria based on evidence-based guidelines using systems like InterQual or MCG Indicia. They also use workflow-focused systems like Iodine AwareUM and Dragonfly Utilize to manage the queue of patients for review, helping prioritize the most urgent patients to review and streamlining the review process. There are also services providers like Corro Clinical Utilization Management and AGS Utilization Management, that help roll out end-to-end utilization review programs.
Other concurrent review solutions take a different approach entirely, and try to bring the concurrent review process back to the physician at the point of care. For instance, AdmissionCare provides physicians with tooling to help them make guideline-driven admission status decisions from within the EHR.
In less urgent cases, procedures undergo prospective review to obtain pre-authorization and validate the medical necessity before services like surgeries or advanced imaging are delivered. While nurses typically use some of the same guidelines products and workflow tooling, there is more direct payer interaction as providers need to go through formal prior authorization processes as part of this process.
Finally, there’s retrospective review, which occurs after the service has already been rendered, which has more use cases related to managing denials, compliance audits, and process improvement, and is generally overlapping with denials management. In many instances, they are referring back to the same clinical guidelines tools as with the other types of reviews, but they are generally trying to deal with bulk audits or large quantities of denials.
Future of Provider Utilization Review
Emerging technologies promise to make UR processes faster, more accurate, and seamlessly integrated into clinical workflows. AI-driven tools can proactively identify high-risk cases, predict resource utilization, and guide evidence-based decisions at the point of care, reducing the administrative burden on clinicians and improving outcomes for patients. We see substantial opportunities to embed smarter workflow systems directly into the point of care, eventually obviating much of the prospective and concurrent review processes.