Utilization Reviews

Utilization Reviews from Omneity Billing

Request a utilization review from Omneity Billing.

What Is A Utilization Review?

A utilization review is a process in which the medical need, appropriateness and efficiency of health care services are evaluated after they have been administered. Ideally utilization reviews benefit both the individual and the health care provider in creating a more efficient streamlined health care process. Unwanted or unnecessary procedures can be avoided, saving both the health care provider and the individual from unwanted additional costs.

Utilization management is a term synonymous with utilization review. Generally utilization management describes approval or analysis of future care and utilization review focuses on past treatments received. Utilization reviews also help health care companies create specific guidelines for certain ailments in hopes of creating a uniform treatment outline.

Types Of Utilization Review:

There are three common types of utilization review.

  1. Pre-certification review – A precertification review describes the preapproval process for receiving treatment commonly covered on your insurance policy. Outpatient surgery, home health care and non-emergency hospitalization are common treatment services that the health care provider wants to ensure are medically necessary. The provider gathers information on your ailment, compares it to information they have on similar cases, and then a committee set up by the insurance company determines if it is necessary. If your claim has been denied you can appeal their decision.
  2. Concurrent review – Concurrent reviews are similar to pre-certification reviews, but instead happen while the person is actively receiving treatment. A concurrent review ensures the patient is receiving timely and effective care.
  3. Retrospective review – Retrospective review is when the insurance company reviews information on treatment a patient has already received. The insurance company can use this to deny coverage a patient has already received.

What If My Utilization Review Is Denied:

If your utilization review has been denied you are entitled to an appeal. Omneity Billing can help individuals and health care providers in the appeals process with their insurance companies.