Making the Right Utilization Review Decisions

As a case manager working in utilization review, you don't want to be denying patients treatments that they deserve. At the same time, you don't want to be preauthorizing expensive and complex procedures that are not within your patients plan language or medical necessity. This is why using an IRO is so important.

It's impossible to know what decision is right in every single case based upon the medical evidence inside the chart. Utilization review professionals simply don't have the time to get all of the facts and work through every aspect of the case before a decision needs to be made and a preauthorization of treatment is allowed. That is why an IRO can greatly expedite the decision making process while ensuring that the decision is made upon the medical evidence and the facts.

If you are a case manager or utilization review nurse and you're not using an IRO to back up your medical decision making, you're not following best practices in today's market place and you could be putting you and your company at risk of making decisions which will end up getting your company into trouble. If you are interested in knowing more about IROs go to the National Association of Independent Review Organization’s website for more information.