Role Of UR Nurses In Medical Utilization Review Process

Medical utilization review (UR) is a critical process crucial for the treatment of patients. This process ensures that the healthcare services are appropriately and efficiently used in favor of patient care. Its essential component is a value-based approach to paying for health care services.

The Goal Of Medical Utilization Review

Medical utilization review ensures that the patient gets the due care administered through proven methods by the appropriate healthcare services provider and delivered in the right atmosphere.

The Outcome Of Medical Utilization Review

The process of medical utilization review results in high-quality care administered to the patient in the best possible manner economically. The process ensures that healthcare services comply with the current evidence-based care guidelines.

Who and Where The Medical UR Process Is Conducted?

There are UR nurses that perform the review services mostly. UR nurses are hired by:- 

• Health insurance companies

• Hospitals

• Home health companies

• Discharge planning team

• The clinical staff caring team

• The social work team

• The quality improvement team

It is mandatory by the government that hospitals should have effective utilization review programs to participate in Medicare and Medicaid. The hospital UR nurse discusses the medical necessity criteria with the insurance UR nurse to justify the payment or suggest an alternative status. In the case of disagreement between the two nurses regarding the situation and the payment, the physicians discuss the medical necessity during a scheduled peer-to-peer conference.

If the disagreement continues, the hospital appeals the case to the insurance company.

There are strict protocols for the UR nurses stating what high-quality care should be provided by Whom and under what settings to the patient. This includes analysis of whether a patient needs admission as an inpatient or should be kept under observation. This is done to calculate the amount health insurance will cover for the patient's hospital stay.

In many situations, the hospital UR nurse also enacts as the discharge planner. This combined job is known as case management.

What Is The Necessity Of The Medical Utilization Review Process?

The UR process is necessary for patients' treatment as hospitals cannot admit Medicare beneficiaries without a UR plan.

The code of federal regulations and the Medicare Benefit Policy Manual states the guidelines to be followed by the hospital and the insurance company.

Types Of UR Services Provided By Healthcare Coding Consulting Services Provider Firm

When the UR is done during the care provided, it is known as concurrent utilization review. On the other hand, it is known as retrospective UR when UR is done after the care completion. A specialized nurse or claims expert performs retrospective reviews that ensure the claims submissions have complete and correct billing codes against the services provided.

Sometimes healthcare coding consulting firms also offer utilization review services as a part of the prior authorization process. This prospective review assesses the requirement for healthcare services before the services are provided to the patients. Under this utilization review process, the provider must submit prior authorizations to health plans to ensure the most appropriate services are rendered.

Role Of Nurses In The Medical Utilization Review Process

Healthcare coding consulting firms provide UR nurses whose primary function is to document the objective information starting from the present situation stated in the nurse's note. This includes

• Oxygen saturation

• Oxygen administration mode

• Pain

• Intake and outtake

• Patient's abnormal signs and symptoms 

Past medical history and other relevant information like the plan of care are part of physician notes.