Utilization Review Services For Rehab Center’s Revenue Cycle

Pre-Authorization Review

If we talk about the various departments of a rehab centers, Utilization Review or utilization management is one of the most important success components. To ensure proper utilization of treatment resources, the process of utilization reviews starts and ends with the hope of confirmation from a health insurance company about the appropriate billing of medical treatment. In the fluid ecosystem of mental health treatment, role and knowledge of a Utilization Review specialist is extremely important in terms of information discussion of:

Optimal utilization of treatment resources
Study and make decisions of patient records for proper case documentation
Scope of Medical treatment
Discuss/suggest continuing treatment plans
Advocate for required patient treatment with medical providers
and much more.

Utilization Review, HIPAA and Documentation

Going by Obamacare insurance mandates and HIPAA guideline, management of utilization review and billing mandate, HMO and PPO insurance types has to be looked from boots-on-the-ground view. To make utilization review process smooth from a qualitative perspective, it becomes extremely important that everything is properly clinically documented.

We promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests.

  • Perform telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
  • Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
  • Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
  • Educate providers on utilization and medical management processes
  • Provide clinical knowledge and act as a clinical resource to non-clinical team staff
  • Enter and maintain pertinent clinical information in various medical management systems

Step 1: UR Requirement Share

The claims examiner (or treating physician in states that require URs) refers the medical treatment plan.

Step 2: Reqd. Information Analysis

Our in-house UR coordinator reviews the claim to verify that we have the required information. Coordinators are trained to know what type of back-up documentation and medical records are needed to process the UR.

Step 3: UR Specialist Assignment

The coordinator enters the information in our UR work flow and assigns the review to the appropriate physician based on his or her area of expertise.

Step 5: Quality Audit

The UR decision moves into our quality assurance process to confirm that state guidelines have been applied and that clinical documentation is in order.

Step 4: Evaluation

The physician evaluates the proposed treatment, verifies that the recommendations conform to state UR guidelines, and renders a decision. In many cases, the doctor will also call the treating physician to learn more about the patient, discuss specific procedures, and/or recommend alternatives.

Step 6: Case Managed

Written results go to all stakeholders, including the claims examiner, treating physician, and patient. The entire process takes less than 24 hours, on average.

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