10 Questions to Ask When Evaluating a Potential Utilization Review Partner

| | Utilization Review

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An efficient and effective utilization review (UR) process must include two major components: intelligent software and exceptional service. UR providers must look at each treatment request individually while applying the evidence-based guidelines particular to the case and state. To show its competency, a UR company should be able to provide detailed answers to critical questions about its technology and quality. When looking for a utilization review partner, ask these detailed questions before making a decision.

Five Must-Ask UR Software Questions

  1. Is there a repository for document and data management?
  2. Is the software fully integrated? Multiple users working remotely must have efficient workflow processes and immediate shared access to medical documentation, case notes and evidence-based guidelines.
  3. How are phone calls and faxes tracked? For example, does the software automatically re-send failed faxes?
  4. Can users easily customize and run reports, including reports that use real-time data to use in managing workflow, tracking performance and detecting patterns in treatment requests and determinations.
  5. Does the software help ensure compliance? Today’s UR software should allow users to create customized data fields to meet all jurisdictional requirements. This includes data capture to allow for fully compliant, automated notification letters?

Two Key Questions about UR Quality

  1. Are the UR nurses required to justify all of their decisions, or is it possible for them to quickly approve requests to expedite large numbers of cases?
  2. What criteria do UR nurses use to base their decisions to move requests to physician review. How often are the nurses’ “no-gos” upheld?
It is important to monitor appeal rates from a cost perspective. Also, UR companies should monitor physician reviewers to identify any patterns of continuously approving or overturning reviews.

Three Critical Questions about Quality Peer Review

  1. What types of doctors do the UR company contract as medical directors and peer reviewers, and what are their qualifications, reputations and track records?
  2. Are peer reviewer reports actually authored by the peer review doctor? If not, how is the process monitored for medical integrity and compliance?
  3. Does the UR company provide evidence-based guidelines and research to peer review doctors to use in making determinations, or does the doctor do independent research?

Fast to Yes, Easy to Know

States regulate the number of days an insurer has to respond to treatment requests. If the treatment is warranted and backed by evidence-based medicine, getting to “yes” as quickly as possible is important. When the answer is “no,” the reviewer should make it very easy for both the claimant and requesting doctor to understand the reason for denial. Time matters, and medical decisions can impact an individual’s quality of life. UR companies must operate efficiently, always be in compliance, and conduct all interactions with high quality. When looking for a utilization review partner, be sure to ask detailed questions, and get the right answers to ensure you’re finding a UR solution that delivers every time.
What are your thoughts? Join UR Nation and let us know!

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.

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