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Utilization review is part of utilization management and is an approach to treatment planning. Inherent in utilization management is the responsibility to assure that the patient receives the quantity and quality of services at the appropriate time in the appropriate setting to be consistent with their medical care needs.

Comprehensive utilization management consists of several components. These components occur along a continuum in an acute care episode. Utilization management in its purest form consists of:

Throughout this continuum is the thread of quality management.

Quality management assures that medically necessary and appropriate care is being rendered in an efficient and effective manner, and that such care meets quality standards and community standards of practice.

The mission of quality management is to assess services rendered by providers through an ongoing effort to improve the quality of health care.

Most HMOs have written standards for what items are reviewed, and what might be considered appropriate for amount, time, and sources of evaluation and treatment. An independent review organization will also perform utilization management functions.

There are any number of variations on this basic theme of utilization management. It may also be conducted on outpatient/ambulatory services/procedures. Utilization management may be conducted on assistant surgeon requests, requests for admission to skilled nursing facilities, home health care, hospice care, and any number of ancillary services such as durable medical equipment and physical therapy. Indeed, utilization management can be performed on almost any health care request.

Utilization management may be performed by the HMO or insurer itself, or it may be outsourced to either a third party review specialist or to the hospital/lab/etc. providing the service. Most frequently, nurses are employed to conduct the actual review. In all cases, the review examines medical records to see if the patient was given an economical level of care consistent with their needs and the past needs of similarly-afflicted patients.

Precertification Review - This type of review requires the certification of medical necessity before a patient can be admitted to an acute care facility or prior to the rendering of outpatient services. It is a process to assure that contemplated elective or non-emergency hospitalization is medically necessary and arranged in an appropriate facility. The review determines the appropriateness of the recommended care and facility, and whether treatment would be more appropriate on an inpatient or outpatient basis.

This review requires the physician and patient to provide basic diagnostic and or planned procedural information to the utilization management personnel BEFORE the patient is admitted to the acute care facility or receives treatment.

This review is normally applied to elective admissions. An elective admission can be defined as a planned treatment that can be delayed for an indefinite period of time without risk of permanent disability. Such procedures might include vasectomies, most hernia repairs, hysterectomy, etc.

The utilization management coordinator compares the request for an elective, inpatient admission to physician approved, goal based criteria.

Urgent admission requests generally occur the same day as the admission. Precertification is requested by telephone in this instance. The same physician approved, goal based criteria are used for this review.

Emergency admissions are not subject to precertification because treatment in these cases must be rendered immediately or there is a risk of permanent disability or death. When a patient is admitted via an emergency admission, notification generally is acceptable within 48 hours of admission or by the second business day after admission. Once notification occurs the utilization management coordinator reviews the case, applying the same physician approved criteria as are used in precertification.

The employee's plan benefit book can provide the specific notification requirements for certification.


Precertification review is intended to control costs PRIOR to a patient being admitted and may be supplemented by continued stay review, discharge planning, case management, assistant surgeon review, ambulatory procedure/service review.

Admission Review - is the review process which is conducted after admission has occurred. All acute care facility admissions are reviewed to determine medical necessity and appropriateness of confinement and to assure early discharge planning. Admission review is performed the first working day after the patient has been admitted to the acute care facility and uses the same physician approved, goal based criteria. This process verifies the accuracy of information received at precertification, the need for the acute level of care, the implementation of planned treatment(s)/procedure(s), and determines any co-existing condition that may have been overlooked in the precertification request.

This portion of utilization management is generally used in the more intensive controlled setting such as HMOs. This review is usually performed on site at the acute care facility.

Once admission is certified, the utilization management process enters its next phase.

Continued Stay Review - is the portion of the utilization management process that assesses the medical necessity and appropriateness of continued confinement. Continued stay review is applicable to all admissions. This portion of review is accomplished by a cyclic approach that compares objective clinical data to physician approved, goal based criteria.

Continued Stay Review is oriented toward reducing the number of days a patient is confined in a facility while retaining quality of care. It also provides the utilization management coordinator with an opportunity to anticipate alternative, less acute, care settings, discharge planning needs, and to identify cases with the potential for catastrophic case management services.

This type of review is "transparent" to the patient unless there is need for the patient to be involved in discharge planning. This review involves either the attending physician and/or the utilization review department of the facility.

This portion of the utilization management process is also the most labor intensive, often requiring many telephone calls to obtain information about any given case. This portion of utilization management is even more labor intensive when performed on-site at the facility. When this occurs, this portion of utilization management is often referred to as concurrent review.

Continued Stay Review is conducted until discharge or an adverse determination is issued.

Discharge Planning - is the process in which the utilization management coordinator coordinates and expedites the transfer of the patient from the acute care setting to an alternative, more appropriate care setting. A more appropriate setting may be a skilled nursing facility, home health care, or a rehabilitation center, to name a few. Effective discharge planning is implemented at precertification review notification.

This process provides the arrangements for continuing care, if needed, after the patient is discharged from the facility. Making plans in advance is extremely important for patients can remain in the facility for days awaiting plans for home care, etc. Delays in discharge are costly to the patient and the plan sponsor.

It is extremely important that the plan sponsor provide for these alternate care options in the plan design and make them financially advantageous.

Discharge planning is most effective when benefit plans include provisions for supplementary skilled nursing facilities, hospice, home health care, along with the appropriate financial incentives to make use of these alternatives. Coverage for these services should be designed to allow for appropriate alternatives to hospitalization and not to encourage excess use of these services.


Retrospective Review - is the process that applies the same process and goal based criteria as continued stay review, only after the patient has been discharged. Retrospective review is not the preferred process for conducting utilization management. This process is used only when absolutely necessary. One major problem with retrospective review is that the patient and provider may not know until several months after the fact, that services will not be covered.



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