Appropriate Utilization of Healthcare Resources 3

Last week I shared information and resources you can use when faced with mounting medical bills. This week I would like to focus on processes that are in place today to ensure appropriate use of healthcare resources.

In the past physicians were not questions as to the care decisions they made.  This is because physicians had the power to write anything they felt the patient needed to treat their medical issues. Once written, the patient’s insurance company would pay the bill without much oversight. As a result of this practice, there was massive overutilization of services that caused healthcare cost to skyrocket. 

Today, there are utilization requirements in place by the payer that providers, physicians and hospital systems need to follow in order for payment to be provided by the payer. These rules may seem burdensome to providers and most consumers, but they have helped to control costs while ensuring the care provided is based on scientific evidence, is timely and in line with the patient condition. These practices have also been shown to have slowed healthcare spending and improved the quality care provided.

The first requirement from the payer is for providers, physicians and hospitals to supply evidence that supports their request for high costs treatments such as diagnostic tests, medications, home care, rehabilitation or other high costs services used to treat patients. The evidence should follow the National Guidelines that payers and providers all have access to.  

Having this system in place allows for a review process to take place by the managed care organization. The physician ordering the treatment must provide their rationale and evidence to support the care before moving forward. The hospital utilization review nurses or the office staff from a physician’s office email the information via or send via a secure fax line to the managed care company to being the review process.

Once a request is received by the insurance company, a utilization review nurse will review the orders and documentation against the national guidelines. If  the information meets the criteria, the orders are approved. If the information does not meet the criteria, then the information is sent to a physician on staff at the insurance company who does their own review and makes a determination. Again, if the physician feels the information meets the guidelines, the care is approved. If not, the reviewing physician will issue a denial. It should be noted that nurses cannot issue denials. Only physicians can make these determinations to deny care.

Managed care organizations have to follow strict timelines to ensure these reviews are done on a timely basis and do not to hold up treatment. If the treatment is denied, the insurance company has to explain why and give the physician or hospital the rationale in writing as to why a denial was given.  

As you can image this is a difficult and controversial process. It is often argued that the ordering physician who knows his patient should be given the benefit of the doubt.  To assist, a process called peer-to-peer review is part of the utilization review process.  The theory behind this process is that the treating physician and the managed care physicians doing the review can take a minute to talk to each other about the patient, the rationale for the orders written, what the treating physician is  looking for and what the expectations are as a result of the treatment.  When this type of discussion occurs, most denials are overturned unless there is strong evidence against the proposed care. Most managed care physician wants to give the treating physician some leeway in treating their patients so the peer-to-peer review is an important part of the process. 

There may be some restrictions put on the treatment to allow for a trial period, but this would be spelled out in the approval letter.  Consumers and hospital case managers should encourage the peer-to-peer discussion as it will assist the process and is a way to advocate for the patient. This process also shows the importance of clear and supportive documentation that defends the plan of care.

If the denial is issued, then the treating physician, the hospital or the patient has the opportunity to appeal the decision. Again, there are strict rules around this concept that all have to follow.

If an appeal is requested, the insurance company has to have a physician who is an expert in the field of the patient’s condition and has had no connection to the physician who did the initial review. This is so that the review process is independent and objective. 

Once the physician asked to do the appeal has an answer, a telephone call, and a letter is sent by the managed care company to the ordering physician. If a hospital or another type provider is involved they would also get notice of the decision as well as the patient. If the appeal overturns the denial decision, then generally the managed care company would abide by the decision. 

If the appeal upholds the denial, then generally, the physician would seek a new course of treatment or the patient has the option to pay for the service if they (and their doctor) feel the course of care is needed. Also, if there are additional avenues for the physician/patient to take that information would be detailed in the letter from the Insurance Company.

As a patient, you have a right and responsibility to participate and be involved in all of these discussions. You can and should encourage your doctor to send in detailed information on your case to prove an explanation as to why care is needed, take part in the peer-to-peer discussion, and appeal the decision if needed. As these processes take time, many physicians do not go through the process unless the patient request for them to advocate for them.

As mentioned previously these processes take time,  but they are in place to ensure that the care recommended is based on the most up to date scientific evidence to meet your needs. 

All of this information is included in your member handbook that your insurance company provides so take the time to familiarize yourself with these processes so you are aware of your rights. Physicians and providers are also well aware of the rules and the process as  part of their agreement when they become contracted to a managed care network.
Again, the utilization management process is in place to ensure the care you receive is:

1. safe  2. evidence-based  3. appropriate for your condition  4. based on your current condition 5. timely 6. cost-effective and 7 approved by the insurance company if there is an approval process required before treatment is rendered.

The role the patient plays in the utilization review process is important as your input can help your
doctor better understand your goals and help them plan your care to fit your needs. Patients should:
  • Understand the treatment recommended
  • If there is more than one treatment option, all options should be explained to the patient by the ordering physician so the patient is given the opportunity to choose the options that best meets their goals. This process is known as shared decision making.
  • Understand if the treatment being ordered and how it will make a difference in your care
  • Understand what the test show or treatment will show or do to improve your care?
  • If you don’t get the treatment, what are the consequences to your condition or life?
  • Are their complications associated with the treatment to be aware of?
  • What costs will the you be responsible if the treatment is approved? You may have a co-payment to make if/when the treatment is approved.
  • Your doctor should be able to answer all of these questions so you can be sure the treatment plan is understood by you. If your physician does not provide the answers to any of these questions, you should question the plan of care as having answers to these conditions are critical.  

With last week’s post, Tackling Medical Bills and this week’s post on Appropriate Utilization of Healthcare Resources, you can see how important it is for patients to understand all their options and to be an active member of the healthcare team.    

The more you understand your care and treatment options, the more likely you are to ask questions, learn, and receive care that meets your goals. When physicians and other members of the healthcare team work with their patients, it leads to improved health care outcomes as well as lower cost of care.

To assist you in better understanding these concepts, here are some articles that will explain the trends that are helping healthcare to be safe, effective, patient-centered, timely and cost effective.  

Shared Decision Making: Engaging Patients to Improve Healthcare: This article explains how being involved can improve your care.Here is the link to read the article.

Appropriate Use of Medical Resources:  TheAmerican Hospital Association provides information that will explain what Utilization Management is and why it is used today to improve care and control health care costs. Here is the link to access the information.

The Role of Utilization Management in Case Management: This article shows that a priority of every case management intervention is to support the patient to make sure that they are getting the best care and support over a continuum of time to achieve positive clinical outcomes.

I hope this information is helpful to you and a refresher to all members of the healthcare team. I look forward to your comments and recommendations for future posts. Please feel free to leave a  comment in the comment section or email me at Have a good week. 

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