Does Your UR Software Keep You Audit-Ready?

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UniMed Direct - 10 Questions To Ask

Audits are a routine but stressful part of your company’s business. The software that guides and manages your utilization review (UR) process should help your organization be ready for regulatory scrutiny at any time.

Insurance companies may be audited for rate-setting or claims practices, and 18 states have auditable utilization review licensing requirements. Sometimes audits are bundled, and sometimes they focus on a specific compliance area. Audits may be random or scheduled well in advance. In some cases, the regulator requires a company to submit data for examination before making a decision to audit. In many states, the likelihood of audit and risk of penalty are very high.

Protect Your Company With Internal Audits

Regular internal audits can protect your company from audit findings that lead to fines and penalties. The best UR software, like ReviewStat® by UniMed Direct, collects data, tracks processes and reduces user error to help companies stay compliant. The software should enable users to access data instantly and manipulate and report it in a way that gives leadership a clear line of sight into real-time quality and compliance.

Monitor & Refine

The data obtained through UR software equips leaders with the information needed to guide the best use of resources and identify treatment categories that are frequently denied or always approved (think compliance risks).

UR data also helps analyze staff workload and performance. It indicates how much work employees are able to do, how long it takes and the quality of their output. It provides a decision trail for the work that happens within the system. The software should generate quality-assurance reports that help management prepare for an audit.

The best utilization review software is built around speed and compliance. It is customized and configured to facilitate frequent internal checkpoints and provide internal controls for your operation. A software system designed to fit your company’s workflow is the best way to make sure you’re operating in compliance and consistently reach your quality goals.

If you have the right software, audits will feel like business as usual. If you don’t, it’s time to assess your software options.

Ask an expert for more information.

Lisa Hannusch

Lisa Hannusch is CEO of UniMed Direct and founder of UR Nation. With experience in virtually every aspect of workers' compensation medical management, she is a nationally recognized authority on effectively managing utilization and medical claim issues. Lisa has direct experience as a healthcare provider, has conducted healthcare fraud investigations leading to prosecution, designed claims and medical software applications, and has worked as an insurance regulator and state agency rule and guideline author. She was an influential leader for requiring evidence-based medical determinations. At UniMed Direct, Lisa has built an industry leading managed care company specializing in ReviewStat – a leader in hosted medical management software, supported with services for UR and a national independent Peer Review Panel.

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