Utilization Review

“Approvals when appropriate and denials that stick.”

MediReview Philosophy
Utilization Review (UR) involves screening certain proposed medical procedures and pharmaceuticals to determine if they are medically necessary and appropriate based upon established review criteria. This includes prior authorization for hospital admissions, all surgeries and diagnostic studies, and concurrent stay review, ensuring that patients are discharged from the hospital when the level of service they are receiving no longer requires inpatient care.

At MediReview, UR is not merely an administrative function. Our nurse case managers and physician advisors utilize the latest evidence-based criteria in evaluating each UR submission.

MediReview’s nurse case managers are specially trained and uniquely skilled to promptly approve appropriate requests for medical services, when supported by nationally recognized criteria.

When the requested service does not meet criteria, the request is referred to a board certified physician advisor. If the reviewer determines that the service is not medically necessary, the denial is supported by written evidence-based documentation. Our client, the patient and the treating provider are promptly notified.

Treating providers and patients have the statutory right to have any denial appealed to a specialty match reviewer. In these situations, MediReview has the request reviewed by a specialty match reviewer who will render an independent opinion on the requested service.

These procedures ensure that the patient receives the right care while helping payors control their medical costs.

Outcome Enhancement
Frequently the UR process identifies patients whose outcome/recovery can be improved through nurse case management. Most often this process lasts 3-6 months and involves consistent interaction between the patient and MediReview clinical staff. Outcome enhancement involves the following areas and helps ensure the best medical outcome:

  • Patient accountability;
  • Identification of post-operative complications;
  • Co-morbid conditions (e.g. diabetes, obesity, cardiovascular disease, etc.);
  • Pharmaceutical compliance and/or complications;
  • Recovery to appropriate benchmarks.

Accessing MediReview’s UR Services
MediReview provides UR services to carriers, third-party administrators, self-funded employers and excess/reinsurance carriers. These services are provided nationwide and can be acquired on a stand-alone basis or in conjunction with other MediReview programs.

For more information about Group Health services, contact MediReview at (800) 850-0281 or info@medireview.biz.