Medical Utilization Review
The purpose of the utilization review program is to safeguard against unnecessary and inappropriate medical care rendered to patients. Medical services and/or records are reviewed for medical necessity, relatedness to the disease or injury, appropriateness of place of service and length of stay (inpatient hospital). The goal is to return the patient to prior injury or illness functioning as quickly as possible.
Comprehensive Consulting performs the following:
- Preauthorization or Precertification review of medical procedures
- Concurrent review of medical services
- Retrospective review of medical services
- Reconsideration of medical services
- Medical Bill Review
- Medical Review Consultations
The payer of medical services wants to be sure it is only paying for appropriate services.
There are three payer standards:
- Medical necessity of services provided
- Appropriate care related to the injury or disease
- Services meet the regulations of the geographic area
Payers are interested in being stringent enough to protect their stockholders and overall viability, but not so stringent as to upset their clients (including the employers that usually pay the premiums).
