The Utilization Review process bridges the gap between all parties including providers, payers, and patients. This process involves the use of certain techniques where the medical provider or facility communicates to the patient's insurance company about the patient's specific needs, why they need medical care, and how the provider plans to treat them. It is the Utilization Review Specialist's job to advocate for the patient, so they are given access to the type of care they need. The prior authorization process allows the patient's health insurance company to manage the cost of their health care by assessing how "appropriate" care is before it is provided. If the insurance company determines that the client does require the type of care the provider is asking for, they provide an authorization number that needs to be included on the claim form that is submitted to the insurance company for payment. If the insurance company determines that the treatment the provider requests is not appropriate, authorization will not be given. If at this time, the provider proceeds to treat the patient, the insurance company will not pay for it. Without proper case management, a provider or facility's potential revenue is limited. Because most clients use insurance to pay for medical care, if you are not able to get treatment approved by the insurance company, you are limited in the number of patients you can see. This is particularly true with behavioral health services - if treatment is not authorized, the insurance will not pay. Proper utilization review requires comprehensive intake assessments, knowledge of the patient's past and current mental state and timely follow-up calls to extend their treatment, if necessary.
Utilization Review Best Practices
Call in the case within 24 hours of admission.
Refer to relevant documents that you receive during the intake assessment. Present symptoms and how they affect the client from functioning at their baseline.
Track the number of days your patient has been given for treatment. Monitor your patient's
progress and if they need more treatment, call in the request days in advance.
Stay organized. Keep a separate file for each patient with a record of any details or critical information you receive from the case manager.
Set a weekly meeting with the patient's clinical care team to discuss how the client is progressing. The more clinical information you have, the better.
Use our tool below to calculate how much you could get paid even before conducting the utilization review.
For more information on this topic and much more, view our Behavioral Health Guide to Quick and Accurate Claims Processing. You can also download the PDF format by clicking on the image below.