Process of Concurrent Utilization Review Essay Example for Free

Process of Con menses recitation Review EssayIn Health Industry, the process of Concurrent purpose Review has its own immenseness for the management of wellness reverence industry enabling them to control the Length of Stay(LOS) of patients in the infirmarys and their use of accessory services. This process is vastly used in the system and procedures adopted in the hospital cargon because of the uplifted be involved in it, though its application keister be put practically in use in other medical settings as well.The Concurrent use review implies that players providing medical take facilites inquire to provide all the info necessary in the health care to their payers who in snatch determine its usability in the current settings of the hospital, before alloting the certificate for reimbursement to the plan. The process has a direct impact on the hospitalized Ameri weed patients who are covered under the health amends schemes. Insurance companies are payers in the field. They all conduct their own reviews or hire a review company to access the level and need of the patient and hospitals are providers who hire its own staff for this purpose.Staff members provide all the clinical information required to be authorized for reimbursement, but the first level of review is conducted by a registered contain who is highly qualified to cover patients of a particular area. Nurses provide all the details of patients to payers including the severity of illness, the length of patients kept on observation and assessment by registered nurses.If patients condition is considered as stable and he or she does not require this assessment then they are kept for observations in settings considered cheap. Second part of the information is the summary of the plan discussed and formulated for the care of patient. Then the role of payers comes in who evaluate this information to render the usability, the importance of this plan for patients and furthermore if this plan has followed the requirements of the terms of the contract signed with the provider. After this process of military rank only, the plan is certified for reimbursement.Mary Ellen Murry went deep further to analyse the extent to look into the practical forte of this process since its application in the Health Industry. There are various aspects to it that Mary Ellen tried to crystallise the payers in the Health Industry to focus on. Reviews are undertaken to make sure that inpatients and outpatients are getting square-toed care in timely manner and the treatment and health care is cost-effective. It also involves assessment of patients health to assure them proper and effective after- care. It is also used to assess if the resources are being used in effect and to differentiate any superfluous or pertinent activity. This is the most crucial strength of this review. Another draw worth mentioning is the point when the planned care is refused certification for reimbursement. In this case both the payers and providers are held answerable for the outcome.In a benchmark case between Wickline v. State of California the court gave the statement that a patient who is harmed when care which should break been provided is not provided should recover from all responsible for deprivation of care, including, when appropriate, a health care payer Third party payers of health care services shag be legitimately held accountable when medically inappropriate decisions result from defects in designs or implementation of cost containment mechanisms A atomic number 101 who complies without protest when his medical judgment dictates otherwise, can not avoid his ultimate responsibility for his patients care. (Murray 2001) This ruling is a reminder to physicians for their duty and obligation in the decision making. Ross too stated in 1996 that according to law, the insurance carriers are bound by the duty to conduct investigation before deciding on refusal of payment. Th is is some other strong point of the importance of conducting reviews according to the existing medical standards. The review is most applicable in all the cases and the immediate feedback provides health authorities uptodate information on the necessary steps needed, shortcomings arising out of the current care and help insurance givers to update themselves with the requisite reimbursements. The visualisation techniqe of stacked bar gives details on the daily plan activities. (Dr. topaz 1998)Concurrent Utilizaton Review is also not without its limitation. Looking at the monstrous number of providers and players involved in this program all over the country, the process needs requisitive number of registered nurses.In case of the shortage,the investment required for their appointments can become burdensome and the studies conducted on some of the institutions also revealed the position that some of the staff members conducting reviews are not registered nurses, though they are i n possession of baccalaureate degree. The hospital authorities claim that these nurses and staff alloted for review are trained in their requisite field and hospitals can substitute assisting staff instead of registered nurses to perform the Concurrent Utilization Review process increasing the handiness of professional nurses.Controversy is going on the extent to which the economic criteria should be taken in the count of providing quality care to the patients. Hereby most physicians feel that without compromising on the quality of the measures adopted for the health care, cost can be minimized. The validity of these reviews is also questioned. It is doubted if these reviews sport been based on evidence from high-quality studies, explicit randomized trials or meta-analyses of multiple trials, which are the key indicators for the trials.If reviews are found not based on the solid evidence then those developing audit criteria should take expert feel. Reliance on opinion and infer ence weakens not only the validity of the criteria for a process-of-care audit, but also the validity of any conclusions derived from applying the criteria. This can be done by having a multi-specialty panel rating on hundreds of different case scenarios depending on the intensity of risks and the panelists make ratings on the basis of literature review and own judgments.Authors involved in Utilization Review process consider cost saving factor as the important criteria in preparing plans for health care. The most effective study conducted I found was by the Wickizer, Wheeler, and Feldstein (1989) who came to the conclusion that these concurrent review programs have led to the Decline of hospital admissions by 13%, inpatient days by 11%, expenditures on routine inpatient services by 7%, expenditures on ancillary services by 9%, and total medical expenditures by 7%. (Murry 2001) They make the use of insurance claims data to determine if cost incurred by the hospitals are matching wit h the increase in expenditures being incured on the outpatients. Results show that reviews conform to the high hospital expenditures instead of higher physician office or outpatient diagnostic expenditures.Another study by Wickizer which was conducted in 1991 found that utilization review was showing reduced expenditures of approximately 15% in the surgical cases and slight reductions of expenditures in the mental health and medical areas. These reductions of expenditures showed there have been denials of certification for reimbursement. They came to conclusion that a UR program restricting access to psychiatric care increases the chance of readmission within 60 days.Another telephonic survey conducted by Remler et al. in 1997 of 2,003, physicians in the United States show the denial rates to be little than 6 per cent in the first rate and 3 per cent subsequently. Both these survyes indicate that the reviews can enable payers to reduce their costs on health care. The policy impli cation could be at the cost of reducing the effectiveness of the health care finally being provided to outgoing patients, but to overcome this, hospitals have comprehensive case management programs, to ensure the proper coordination of the care related services including proper utilization of resources.These case managers make a point that every patient has both hospital care plan, including a discharge plan, and along with that a team of clinical social work and case manager associates, are responsible for the conduct of the UR function. And if this process keeps on going in all the hospitals and other clinics and health care institutes in letter and spirit, then the anticipated denial rates will be reduced to a considerable degree.REFERENCE LISTMurray M.E. 2001. Outcomes of Concurrent Utilization Review. Nursing Economics , 19 (1). 7 pg.Tan J. K.H. 1998. Health Decision Support Systems. Maryland Aspen Publishers.