Utilization Review Made Easy

Are you a utilization reviewer or case manager who struggles with the moral dilemma of denying patients the care that you believe they should have, even though it's not covered under their plan language? We talk to many managed care nurses who face this dilemma. In fact, some of those people that we talk to have actually left those positions because they're tired of forcing patients to get care which is not substantial enough in order to treat them properly.

If you're a utilization review nurse and having a hard time with this, one way that you can greatly enhance your ability to deliver the right health care and make sure that nobody gets denied treatments that they deserve is by employing the services of an independent review organization (IRO). Why is this? IROs work to ensure that patients get the coverage that they deserve under to the plan language and according to the standard of care and make sure that the patients medical necessity is always put at the highest level of priority when it comes to making those care decisions. IROs employ doctors and physician peer specialists capable of reviewing the details of a patients chart notes and making the right decisions.

Typically, an IRO's default decision when ruling on care decisions is "Yes." Why is this? Because most managed care organizations do want to do the right thing for their patients and their subscribers. Managed care organizations and utilization review companies actually pay IROs to make sure that there is no systematic denial or bias against patients as they make those decisions on health care utilization.

If you're a utilization review nurse or case manager looking to make sure that your patients get what they deserve, consider outsourcing the most complex and difficult cases systematically to an IRO. What you'll find is the consistent application of evidence based decision making at the highest levels, deploying specialists who treat patients in the same area as each case involved. This will allow you to avoid any misgivings about whether or not effective decisions are being made and patients are getting what they deserve.