Utilization Review & The Role of Independent Review Organizations

This article points to the critical role that utilization review plays in effective medical management, and the increased exposure that organizations face if they don't review the medical necessity of advanced patient treatments and hospital stays . With constantly changing care standards, the need to protect the integrity of patient care while limiting the impact of increasing costs, UR professionals play a pivotal role in today's health care delivery system.

UR organizations are only as good as the medical specialists who review their more advanced cases. For this reason, most medical management firms and UR organizations tap into the peer specialist capabilities of an independent review organization (IRO), which provides them with pre-authorization of their most complex and difficult claims. Since UR organizations can't afford to build/maintain a panel of these specialists, IROs represent a cost effective alternative which allows them to ensure that all complex claims determinations are made by board certified specialists who are in active practice. We provide these services to hundreds of UR and case management professionals in leading health care payor organizations across the US.

May 12, 2008

Strong Utilization Review Committees Can Prevent Inappropriate Hospital Admissions

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

By Nina Youngtrom, Managing Editor, (nyoungstrom@aispub.com)

With all the pressure they face to reduce medically unnecessary admissions, hospitals need strong utilization review (UR) committees — especially since there have been few consequences for physicians whose admission decisions conflict with strict Medicare regulation and guidance (though that is starting to change).

An effective UR process, powered by highly trained case managers and physician advisers, is a great way to help prevent inappropriate inpatient admissions, according to Atlanta attorney Mitch Mitchelson, who represented the first hospital to settle a false claims lawsuit for alleged medically unnecessary inpatient admissions, and physician Robert Corrato, M.D., CEO of Executive Health Resources in Newtown Square, Pa., who served as a medical-necessity expert in the case.

Increased Scrutiny on Admission Necessity

Admission necessity has probably never faced more oversight - from recovery audit contractors, Medicare quality improvement organizations and program safeguard contractors (which are morphing into zone program integrity contractors). With advances in medicine and technology, more procedures can be performed on an outpatient basis, putting pressure on hospitals to establish inpatient medical necessity.

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