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Process of Concurrent Utilization Review Essay

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In Health Industry, the process of Concurrent Utilization Review has its own importance for the management of health care industry enabling them to control the Length of Stay(LOS) of patients in the hospitals and their use of ancillary services. This process is vastly used in the system and procedures adopted in the hospital care because of the high cost involved in it, though its application can be put practically in use in other medical settings as well.

The Concurrent utilization review implies that players providing medical care facilites need to provide all the information necessary in the health care to their payers who in turn determine its usability in the current settings of the hospital, before alloting the certificate for reimbursement to the plan.

The process has a direct impact on the hospitalized American patients who are covered under the health insurance schemes. Insurance companies are payers in the field. They either conduct their own reviews or hire a review company to access the level and need of the patient and hospitals are providers who hire its own staff for this purpose.

Staff members provide all the clinical information required to be authorized for reimbursement, but the first level of review is conducted by a registered nurse who is highly qualified to cover patients of a particular area. Nurses provide all the details of patients to payers including the severity of illness, the duration of patients kept on observation and assessment by registered nurses.

If patients condition is considered as stable and he or she does not require this assessment then they are kept for observations in settings considered cheap. Second part of the information is the summary of the plan discussed and formulated for the care of patient. Then the role of payers comes in who evaluate this information to see the usability, the importance of this plan for patients and furthermore if this plan has followed the requirements of the terms of the contract signed with the provider. After this process of evaluation only, the plan is certified for reimbursement.

Mary Ellen Murry went deep further to analyse the extent to look into the practical effectiveness of this process since its application in the Health Industry. There are various aspects to it that Mary Ellen tried to make the payers in the Health Industry to focus on. Reviews are undertaken to make sure that inpatients and outpatients are getting proper care in timely manner and the treatment and health care is cost-effective.

  It also involves assessment of patients’ health to assure them proper and effective after- care. It is also used to assess if the resources are being used effectively and to differentiate any superfluous or pertinent activity. This is the most crucial strength of this review. Another point worth mentioning is the point when the planned care is refused certification for reimbursement. In this case both the payers and providers are held responsible for the outcome.

In a benchmark case between Wickline v. State of California the court gave the statement that: “a patient who is harmed when care which should have been provided is not provided should recover from all responsible for deprivation of care, including, when appropriate, a health care payer … Third party payers of health care services can be legally held accountable when medically inappropriate decisions result from defects in designs or implementation of cost containment mechanisms …

A physician who complies without protest … when his medical judgment dictates otherwise, can not avoid his ultimate responsibility for his patient’s care. (Murray 2001) This ruling is a reminder to physicians for their duty and obligation in the decision making. Ross too stated in 1996 that according to law, the insurance carriers are bound by the duty to conduct investigation before deciding on refusal of payment. This is another strong point of the importance of conducting reviews according to the existing medical standards.

            The review is most applicable in all the cases and the immediate feedback provides health authorities uptodate information on the necessary steps needed, shortcomings arising out of the current care and help insurance givers to update themselves with the requisite reimbursements. The visualisation techniqe of stacked bar gives details on the daily plan activities. (Dr. Tan 1998)

Concurrent Utilizaton Review is also not without its limitation. Looking at the large number of providers and players involved in this program all over the country, the process needs requisitive number of registered nurses.

In case of the shortage,the investment required for their appointments can become burdensome and the studies conducted on some of the institutions also revealed the fact that some of the staff members conducting reviews are not registered nurses, though they are in possession of baccalaureate degree. The hospital authorities claim that these nurses and staff alloted for review are trained in their requisite field and hospitals can substitute assisting staff instead of registered nurses to perform the Concurrent Utilization Review process increasing the availability of professional nurses.

Controversy is going on the extent to which the economic criteria should be taken in the matter of providing quality care to the patients. Hereby most physicians feel that without compromising on the quality of the measures adopted for the health care, cost can be minimized.  The validity of these reviews is also questioned. It is doubted if these reviews have been based on evidence from high-quality studies, definitive randomized trials or meta-analyses of multiple trials, which are the key indicators for the trials.

If reviews are found not based on the solid evidence then those developing audit criteria should take expert opinion. Reliance on opinion and inference weakens not only the validity of the criteria for a process-of-care audit, but also the validity of any conclusions derived from applying the criteria. This can be done by having a multi-specialty panel rating on hundreds of different case scenarios depending on the intensity of risks and the panelists make ratings on the basis of literature review and own judgments.

Authors involved in Utilization Review process consider cost saving factor as the important criteria in preparing plans for health care. The most effective study conducted I found was by the Wickizer, Wheeler, and Feldstein (1989) who came to the conclusion that these concurrent review programs have led to the “Decline of hospital admissions by 13%, inpatient days by 11%, expenditures on routine inpatient services by 7%, expenditures on ancillary services by 9%, and total medical expenditures by 7%.” (Murry 2001) They make the use of insurance claims data to determine if costs incurred by the hospitals are matching with the increase in expenditures being incured on the outpatients. Results show that reviews conform to the higher hospital expenditures instead of higher physician office or outpatient diagnostic expenditures.

Another study by Wickizer which was conducted in 1991 found that utilization review was showing reduced expenditures of approximately 15% in the surgical cases and slight reductions of expenditures in the mental health and medical areas. These reductions of expenditures showed there have been denials of certification for reimbursement. They came to conclusion that a UR program restricting access to psychiatric care increases the chance of readmission within 60 days.

Another telephonic survey  conducted by Remler et al. in 1997 of 2,003, physicians in the United States show the denial rates to be less than 6 per cent in the first rate and 3 per cent subsequently. Both these survyes indicate that the reviews can enable payers to reduce their costs on health care.  The policy implication could be at the cost of reducing the effectiveness of the health care finally being provided to outgoing patients, but to overcome this, hospitals have comprehensive case management programs, to ensure the proper coordination of the care related services including proper utilization of resources.

These case managers make a point that every patient has both hospital care plan, including a discharge plan, and along with that a team of clinical social work and case manager associates, are responsible for  the conduct of the UR function. And if this process keeps on going in all the hospitals and other clinics and health care institutes in letter and spirit, then the anticipated denial rates will be reduced to a considerable degree.


Murray M.E. 2001. Outcomes of Concurrent Utilization Review. Nursing Economics , 19 (1). 7 pg.

Tan J. K.H. 1998. Health Decision Support Systems. Maryland: Aspen Publishers.


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