The Top 3 Things Utilization Review Considers In A Workers' Comp Claim.
Workers'
compensation is a system in the United
States and many other countries that provides benefits to employees who are
injured or become ill due to their job. State governments usually administer
the program as part of social welfare programs.
One essential part of the
workers' compensation system is utilization review. Utilization review is how
an insurance company or other entity reviews requests for services to determine
if the services are necessary and appropriate. This article will discuss the
top three things you must know about utilization review in a workers' comp
claim.
What is Utilization Review?
Utilization review (UR) is a process by which an organization reviews the use of
health care services and resources. The goal of UR is to ensure that patients
receive the proper care at the right time and in the right setting. UR is a
critical part of ensuring that health care resources are used efficiently and
effectively.
There are two main types
of UR: retrospective and prospective.
Retrospective UR reviews past claims to determine whether services get provided
by pre-determined standards.
A retrospective
utilization review (RUR) is a quality improvement tool that helps organizations
identify and correct problems using resources. The goal of a RUR is to improve
the efficiency and effectiveness of resource utilization by examining past use,
identifying trends, and making recommendations for change.
A RUR typically takes the
form of a meeting, during which a team of analysts reviews data collected from
various sources, including medical records, billing data, and pharmacy claims.
The section then discusses potential areas of improvement and makes recommendations
to management.
Prospective UR reviews current claims to determine whether services are
appropriate for the patient and meet established clinical guidelines.
A prospective utilization
review (UR) is a medical review process that is performed before services are
rendered to a patient. A potential UR's job is to ensure that the services
supplied are medically essential and match the insurance plan's regulations.
Both the patient and the
provider benefit from this type of review. The patient can get assured that
they are receiving the necessary care, and the provider can be confident that
they are providing services that will be reimbursed.
UR typically looks at medical
necessity, appropriateness of care, and quality of care.
Medical Necessity: Medical necessity is a term used in health insurance to
describe the services or supplies covered by a health plan. Providers also use
the time to explain the services they provide. Health insurance plans do not
typically cover services and supplies that are not considered medically
necessary.
Many factors determine
whether a service or supply is medically necessary. These factors include but
are not limited to the diagnosis, the type of service or supply, the patient's
age and medical history, and the availability of less expensive alternatives.
Appropriateness Of Care: When a patient is hospitalized, the utilization review nurse is
one of the many professionals who may be involved in their care. The
utilization review nurse's job is to assess whether or not the care the patient
is receiving is appropriate. It may include reviewing the patient's chart,
talking to the doctors and other health care professionals providing care to
the patient, and contacting the patient's insurance company.
If the utilization review
nurse determines that the patient's care is inappropriate, they may recommend
that the patient be discharged from the hospital.
Quality of Care: One of the most critical aspects of utilization review is
assessing the quality of care that has been provided. It is done by reviewing
patient outcomes, as well as by evaluating the appropriateness of care
processes.
What Happens If UR Finds That
Services Are Not Medically Necessary?
An insurer can refuse to
fund a service if it is not considered to be medically necessary. It is a
case-by-case determination based on the specific services in question and the
insurance plan in place. If a service is not considered medically necessary,
the patient will likely be responsible for the cost of the service.
If you have further
questions about UR or if you have been injured on the job, visit us at Gaylord
and Nantais or give us a call at (562)
561-2669/(213)
732-3436/(805)
800-8799 to speak with a workers'
comp specialist. We can help you understand your rights and make sure you
receive the benefits you deserve.
#workercompensationattorney
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