Medical Utilization Reviews

Often the review of medical records is used to conduct a medical utilization review

. Recommendations from the medical records reviews may include such things as: (a) improvements that are suggested to reduce the under-utilization of services, (b) improved clinical decision making, (c) requirements for continuing education, (d) quality improvement strategies, (e) analysis of provider claims data to identify screening problems, and (f) methods to improve clinical outcomes.

Some of the processes for a quality medical records review can be done in-house, or the entire process may be outsourced. For example data collection can be done by the provider that would include such things as patient eligibility, fee-for-service billing rates and charges, and any date that is available from managed care programs. The analysis of the data is then performed by a medical records review specialist. This is an outside team that does not have any particular bias in defending or upholding the providers actual policies or practices, but instead is train in the best practices as they are known to be effective in a particular subset of the health care industry.

Quantitative statistical analysis and sampling of the data is done at first to identify which medical records and their treatment results nee further scrutiny. This data mining procedure results in a high level of accuracy in identifying which medical records may be problematic and therefore can be thoroughly examined. The samples of the records that are analyzed represent a sufficient amount of the total records to provide reliable study results. Usually these records are examined at the providers site but the work can also be done off site.

The medical records reviews can consist of reviews for third party administrators, health plans and self-insured companies. These reviews are also done to show compliance with federal government programs such as Medicare or Medicaid and are used in the cases of disputes over reimbursements or in the case of legal procedures and appeals. They are very effective support for appeals based on systematic denial of claims. The results may be categorized into such grouping as those of medical necessity, appropriate treatment and hospital care, quality levels and identify those case that are experimental or investigational.

It has been shown that a medical utilization review uncovers wasted staff time, identifies equipment that sits idle, and can be used to eliminate wasted resources. Contrary to the proposition that medical utilization reviews are geared towards cost reduction to the detriment of patient care standards, the opposite overall results are possible, where patient care standards are improved through reallocation of equipment resources and reduction of down time and waste.

by: Talking Heads

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