Utilization Review: In-house or Outsource?

Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care.

Hospitals benefit from outsourcing utilization review in several ways, as it can:

  • Free up in-house physician advisors and chief medical officers to concentrate on other strategic work like policy development, improvement initiatives, personnel management, dealing with complex claims and appeals, and more.
  • Ease the burden of dealing with fluctuating claims that occur with seasonal lulls, physician vacations, and epidemics (or pandemics, for that matter).
  • Provide additional resources such as Peer-to-Peer reviews, payer insights and internal audits.
  • Enable faster turnaround times, often a two-hour window.
  • Streamline the review process.
  • Lower cost in terms of staffing.
  • Shorten the revenue cycle as more denials can be immediate reversed without long appeals.
  • Cover reviews 24 hours a day, 7 days a week, 365 days a year.

What cannot be overlooked as a major benefit for outsourcing UR is that the physician advisors providing the service, who have knowledge of all current CMS guidelines and specific experience in reimbursement policies, can relieve the burden on clinical staff. They can perform UR duties in a cost-efficient, timely manner and ensure the proper level of utilization services. This allows treating physicians to focus more on patient care. While utilization management is often associated primarily with cost containment — and that is undeniably a major goal – improving care is also a high UM priority. Both the goals of cost containment and improved care are met when hospitals can reduce claim denials through effective utilization review.

 

 

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