Today’s medical management professionals may work on the same claim from different offices, different cities or even different countries. At the same time, communication between them is more important than ever. To achieve effective utilization review-bill review integration, information must flow quickly between the physician, the UR nurse and the BR auditor. Efficient touchpoints and “doing things right the first time” are of paramount importance to claimant well-being and the payor’s bottom line.
The Treating Doctor
The injured employee reports to the treating doctor, who begins primary care. Services may include diagnostics and/or treatment. For example, for a lumbar injury, the initial care might include physiotherapy and/or medication, and then an MRI that indicates the need for more invasive procedures such as surgery. The doctor may or may not assign diagnostic codes (ICD9) and procedure codes (CPT) that identify the recommended level of service. It is imperative that the physician clearly document as much information as possible to ensure the UR company makes the right determination.
The Utilization Review Nurse
The medical documentation must then go to the utilization review nurse. Depending on jurisdictional regulations, the nurse may assign codes, if the health care provider has not, and will pre-authorize the treatments that are to be covered under the insurance claim. The combination of the physician’s report and the nurse’s evaluation may be sufficient to pre-authorize the treatment. If not, the nurse sends the case to a physician reviewer. This is a critical point for integrated communications. To save time and money, and ensure appropriate determinations, there should be little need to request clarification from the treating doctor or physician reviewer.
The Bill Review Auditor
From the UR nurse, the case moves to a bill review auditor, whose responsibility includes checking the codes and timeframe for treatment (beginning and end dates) and making sure the correct body part involved in the claim has been identified. The bill auditor then processes the bill for payment in accordance with applicable fee guidelines.
The more detailed the notes and data, the better. This is particularly true when a patient may require additional treatment. For example, if 12 sessions of physiotherapy were approved, but the patient has completed only six of them, and then asks for additional therapy, the nurse’s notes may help get approval for the additional treatment. There may have been mitigating circumstances, such as family illness, that would explain the break in treatment.
This is where the human element is critical. The best utilization review and bill review firms realize that their reputations rely not only on the science of providing data that will pass the test of scrutiny, but also on the art of dealing with people with compassion and care. The combination of art and science is only possible when all three roles in the UR process integrate efficiently.