Conducting Concurrent Utilization Reviews

Conducting Concurrent Utilization Reviews

Concurrent Utilization Review (UR) is a process that helps determine the most effective utilization by the hospital. Utilization includes the services that will be rendered and especially the length of stay that will allow for maximum recovery to the patient but minimum cost to the hospital. It also helps the insurer determine how much if any of the service will be covered.

The process has many benefits, but there is a tendency in hospitals to over think the process and often put too many resources into utilization review that don't justify the amount of return that the review provides.

For example, there are many claims that utilization review produces cost savings to the hospital. The cost savings come in the form of lower admission rates, lower expenditures on inpatient services, and a decrease in cost of ancillary services. This results in a reduction of cost for the provider.

The long term effect for this short term reduction in cost may prove to be negative. The reduction in utilization by the reviewers, which are employees of the hospital, may be based on decisions that are less than informed and therefore less than desirable. The less informed decisions are because the utilization reviewer is frequently not a physician. This may ultimately result in the decision for less utilization causing it to be necessary to treat patients in the future that were initially denied care due to the utilization review.

One area that many providers view as a great candidate for frequent utilization reviews is the length of stay. Length of stay can easily be adjusted to balance the needs of the hospital with the ultimate well-being of the patient. If length of stay is too short it may result in re-admission of the patient, if it is too long, it will result in unnecessary cost to the provider or insurer. The utilization reviews of length stay are usually very effective in reducing cost and maintaining quality patient care. This is a very positive

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