Utilization review helps healthcare teams to navigate between underutilization and overutilization. This essential process helps healthcare teams refine their decision-making processes, improving the synergy between patients, providers, and insurers.
For any healthcare organization that engages in this process, it’s crucial to have a structured utilization review management program in place, along with sufficient staff training. In this healthcare utilization review primer, we’ll step through the basics of utilization review and the importance of training and management for optimizing the review process.
What Is Healthcare Utilization Review?
Healthcare utilization review is an evaluation of a healthcare service to determine whether or not the service is medically necessary. A more nuanced definition would note that utilization review ensures that patient interventions align with evidence-based reasoning and standards.
Utilization review is a high-stakes process that influences major care decisions.
The utilization review process is time-consuming and involves some of the financial and bureaucratic aspects of healthcare that many practitioners would rather not think about.
However, the review process plays an essential role in modern healthcare. Utilization review enhances the healthcare delivery process, leads to effective use of resources and staff time, and ensures reimbursement for needed care.
The Objective of Healthcare Utilization Review
Essentially, utilization review aims to strike a balance between doing too little and doing too much. Utilization review goes hand-in-hand with discharge planning to reduce readmission rates and empower providers to spend their time where it’s most needed.
The process emphasizes:
- Achieving the best possible outcomes for patients
- Using the most appropriate amount of resources
- Maintaining treatment for the most appropriate amount of time
Utilization review also helps prevent negative legal or financial outcomes that can occur when care is provided or withheld inappropriately.
The Role of Training in Healthcare Utilization Review
The Importance of Training
Utilization review is a specialized task. As such, staff who perform utilization reviews should be properly trained and supported. Well-structured training programs improve the effectiveness of the review process, resulting in consistent outcomes that benefit an organization and its patients.
Key Elements of Effective Utilization Review Training
Utilization review training involves equipping trainees with a deep understanding of resource allocation, resource limitations, and how resource use is optimized for effective healthcare delivery. Important components of training may include how to use management software, ethical considerations, and a detailed overview of insurance policies.
Identifying Overutilization
Overutilization—the inappropriate commission of healthcare services—is notoriously tricky to both prevent and identify. Labeling cases of overuse involves detailed investigations and subjective assessments of the need for services and their potential benefits and harms.
Nevertheless, overutilization is a systemic issue that must be addressed diligently in order for a hospital to provide the best care and be reimbursed accordingly. This involves thorough training for utilization review staff, sufficient resources devoted to utilization review, and effective use of management software.
Management Strategies for Optimal Healthcare Utilization
Staff Scheduling and Hiring
Utilization review is performed by nurses or other qualified professionals. Hiring and scheduling for this work should be data-driven, precise, and flexible, like with all healthcare staffing decisions. However, compared to direct care roles, utilization review staff enjoy workloads that are more stable and predictable, making it easier to arrange long-term schedules.
Improving Resource Allocation
Utilization review improves the efficiency of resource allocation. Resulting benefits include minimized wasteful spending, fewer disputes with insurers, and improved patient care quality. This process works best when management software is leveraged to speed up analysis and ensure that allocation decisions are driven by data.
Optimizing Use of Staff Time for Patient Care
When utilization review operates effectively, patients benefit from more efficient use of their providers’ time. By reducing instances of overutilization, more resources are available where they’re needed most.
Healthcare Utilization in High-Stress Hospital Systems
For hospitals with high patient volumes and strained resources, effective utilization review is particularly essential. In a high-stress system, utilization inefficiencies can impact both the organization’s bottom line and the quality of care.
A well-executed utilization review process prevents costly overutilization. This helps a stressed healthcare system to better manage resources, reduce staff burnout, and maintain excellent care quality.
Optimize Your Healthcare Utilization with MorCare
At MorCare, we offer software solutions that help hospital administrators make the most of their resources. Our utilization review and management software helps healthcare teams strike the complicated balance between underutilization and overutilization. To learn more, connect with MorCare today.
