How To Prepare For A Utilization Review


As a physician preparing for a utilization review, there are a number of issues you are concerned with conveying to the physician conducting the review. Regardless of how many utilization reviews you’ve been a part of, you may have some questions or concerns about any given review that you are a part of. Here are a few important ways in which you can prepare for your next utilization review.

Ask Yourself Whether It is Possible That Your Patient Does Not Need to Be Hospitalized

This may seem obvious, but before the review itself, critically assess whether your patient does in fact require hospitalization. Has their condition changed at all over the last three days? Is there any chance they could benefit from being admitted to a facility that offers lower level care?

Often patients are admitted to hospital care as a bit of a default when they could in fact receive more than adequate care at a facility like a nursing facility or a convalescent center. What are the specific reasons that you believe one of these facilities would not offer adequate care? Make sure that you have outlined and articulated the reasons for your position. If your patient has a severe or terminal illness, be aware of their desires in terms of the degree of care they wish to receive. Have they signed a DNR? If so, do you anticipate palliative care being imminent?

Have you discussed with the patient and their family where they would like that type of care to occur? If a patient is being held for testing, assess the degree to which these tests must be conducted in a hospital setting. Be prepared for the physician conducting the review to inquire as to whether an outpatient setting may be more appropriate.

When a Patient Has a Need for Hospitalization, Make Sure This Is Clearly Indicated in Their Charts

Insurance companies will make their decisions about whether patients require hospital care based on the specifics of each patient’s case. Make sure that you have not taken any part of the patient’s case for granted. If a patient is there for only a 24 hour stay, make sure you have noted that rather than simply indicated that they have been admitted.

Also ensure that you have clearly documented any specifics of a patient’s case that make it necessary for them to remain admitted. If a patient is vomiting despite administration of anti-nausea medicine, for example, or if they are unable to wal, make sure that this information is being conveyed to both the insurance company and the doctor conducting the review via the patient’s chart.

Think Like A Reviewer

Go into any review with a reviewer’s point of view in mind. Know that they are looking for ways in which a patient may be unnecessarily hospitalized or receiving too much care, and generate a list of questions they may ask based on this information. Once you have identified what questions may be asked of you by a reviewer, you will have a good sense of what part of a patient’s case may raise questions.

Have a strong defense ready to address any questions that you see arising about your patient. Be prepared to articulate the decisions you have made about your patient’s care and to have strong points prepared to explain how you arrived at those decisions. Make sure that any notes you have made in a patient’s records are legible and accurately reflect any progress you’ve noticed over the course of multiple exams or tests. Always make sure that your point of view is clearly explained and that you have done all you can to work as an advocate for your patient.