Things I Didn't Learn in School: Utilization Review

Utilization Review (or UR) is a fancy way of saying insurance review - it is the process health care providers have to go through to get health insurance companies to pay for treatment. While some internships provide an opportunity for students to learn this process, many don't (mine didn't), and it is certainly not covered in class curricula (which foster the illusion that being clinically correct is the only thing that matters). I imagine I'm not the first to tell you this illusion is false: clinical correctness matters...but only if you can convince a client's insurance company to pay for the treatment they need. If you can't convince the insurer, you won't be able to provide treatment, regardless of what your client needs (unless you happen to work with folks who are independently wealthy...).

While insurance companies claim that the purpose of UR is to ensure that their "members" receive the best care possible, we all know that a primary goal for the company is to contain costs. While they have an obligation to cover necessary services, they want to avoid paying for anything unnecessary, or ineffective. As a result, a primary focus of UR is the medical necessity of treatment. Most basically, you have to demonstrate that there is a clinical condition that is impairing the client's functioning and requires the recommended treatment (rather than a less-costly alternative). 

Classes address level of care from the perspective of ethical mandates to preserve clients' self-determination by providing treatment in the "least-restrictive environment" that allows for client safety and treatment effectiveness. In the UR process, however, level of care translates into cost: higher levels of care are more expensive. As a result, we have to make the case that the client would be unsafe, decompensate, or at least fail to improve at a lower level of care than whatever we're recommending. Even with a solid argument against lower levels of care, however, insurance may push back if the client has already exceeded expected/average duration of treatment at that level of care. 

That brings us to the trajectory of UR over the course of treatment. For most insurers, UR begins with prior authorization (also called pre-authorization, or pre-certification). Clinicians have to provide a diagnosis with supporting clinical evidence, make an argument for the medical necessity of the recommended level of care, and identify concrete treatment goals that cannot be achieved at a lower level of care. If the clinician has made a good case, the insurance company authorizes an initial number of days/units/sessions, depending on the level of care (e.g., days for inpatient, sessions for outpatient). Typically, the more expensive the treatment, the smaller the duration of treatment covered by the initial authorization; for example, I've seen an average of 3 days inpatient, 1 week partial hospitalization, and 8-12 sessions in intensive or standard outpatient.

Once the initial authorization has been used (or expires - they also have time limits), the clinician calls back to request additional time if necessary. They still have to demonstrate the medical necessity of this level of care, but also have to summarize what treatment has been provided, the client's response, goals for continued treatment, and the plan for discharge (e.g., a transition to a lower level of care). Obviously each concurrent review should show that the goals identified in previous reviews have been addressed, whether or not they have been met; if a goal has not been addressed, a solid reason should be provided. If medical necessity is unclear, or the client has already exceeded an average length of treatment, the insurance company may require a "doc-to-doc," where a physician employed by the insurer reviews the case with a physician or other licensed provider at the treating facility, and then makes a determination.

Once a client is able to be treated at a lower level of care, another call is made to the insurance company, summarizing the client's condition at discharge, verifying the total amount of treatment provided, and outlining the aftercare plan - what treatment will follow. This includes any outpatient appointments that have been scheduled, and in the case of a transition to any level of care other than standard outpatient, obtaining an initial authorization for that treatment.

Finally, some insurance companies will occasionally perform random audits of medical records to verify that treatment they've paid for was provided as described by clinicians, and was consistent with the contact between insurer and treatment facility. Medicare and Medicaid are most known for such audits, which are particularly crucial for Medicare because it does not conduct UR before or during treatment. Documentation is crucial to avoid owing money back to the insurer!

What tips do you follow for successful UR?