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Utilization ReviewUtilization review is the term used for monitoring appropriateness of hospitalization for patients in a hospital.Most patients are hospitalized while someone else pays the bill. That someone wants to be sure that the bill isn't excessive or inappropriate. Utilization review can be performed either by the third-party payer or by a department of the hospital. Frequently, the hospital will contract with the payer to perform the utilization review on the payer's behalf. In all cases, the utilization review department is usually involved in transmitting information about the patient to the payer. The information usually comes from documentation in the medical record. Its important to understand the relationships and the interests of the parties involved. The payer wants to be sure it is only paying for appropriate services. There are two standards; medical necessity and covered services. Payers are interested in being stringent enough to protect their stockholders and overall viability, but not so stringent as to upset their clients (including the employers that usually pay the premiums). The hospital wants to be paid for the services it provides. If the hospital doesn't get paid for its services, it will go out of business. Employees of the hospital get this message loud and clear. The Utilization Review (UR) department of the hospital works in the interests of the hospital. UR staff interests are balanced by wanting to keep patients, and physicians happy, so they will keep using the hospital, and to market hospital services by sharing this choice with others. The physician is responsible for the medical care of the patient. That means being an advocate for the patient. The physician's interest to give the patient what he or she wants is balanced by needing to keep privileges at the hospital, and part of the panel of physicians paid by the payer. When a claim is denied, respond. Review documentation, supply additional information and persist in assuring that payment is made for appropriate care.
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