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PubMed1990

Reducing hospital use and expenditures through utilization review. Findings from an outcome evaluation.

Utilization review (UR) has become a prominent approach to cost containment now used by almost 65% of private group insurance plans. Although insurers have increasingly relied on UR to contain health care costs, until recently little was known about the effects of this cost containment approach. This article reviews some of the key findings of a UR evaluation, based on analysis of claims data on 223 insured groups for the years 1984 through 1986. The evaluation found that UR reduced admissions by 12%, inpatient expenditures by 8%, and total expenditures by 6%. It was estimated that UR generated net savings of $115 per employee per year. Groups adopting UR with high baseline rates of hospital use had larger expenditure reductions and greater net savings. It appears that UR can play an important role in private cost containment and help improve medical care resource consumption.

Cost Control↗
PubMed1987

Communications between insurers and providers.

Physicians are frequently distressed by their communication with insurers. This article describes the process insurers utilize to collect data, set reimbursement rates, and utilize peer review.

Communication↗
PubMed1998

Effects of utilization management on patterns of hospital care among privately insured adult patients.

OBJECTIVES: This study examined the effects of utilization management review activities on patterns of hospital care among a sample of adult patients insured through a managed fee-for-service plan. METHODS: The study was a retrospective analysis of insurance administrative data representing a case series of patients for whom utilization management review was performed. Two review activities were analyzed: pre-admission review and concurrent (continued stay) review. Patients were 49,654 privately insured adult patients reviewed for care between January 1989 and December 1993. Review outcomes included inpatient or outpatient care denied, site of treatment shifted (from inpatient to outpatient), or reduction in requested hospital days (total days requested - total days approved). RESULTS: Few patients (<1%) were denied care at time of admission or were required to obtain outpatient instead of inpatient care. More common was action taken to limit length of stay by concurrent review, which accounted for 83% of the total reduction (25,197 requested days) in inpatient care. Utilization management became more restrictive with time: the number of days approved declined by 15% to 50% from 1990 to 1993, depending on the type of admission. Utilization management was most forceful in restricting care for mental health patients, who represented 5.7% of the study population but accounted for 54.7% of the total reduction in requested days. CONCLUSIONS: The utilization management program appeared to limit hospital care by managing length of stay once patients were admitted. The effects of restricting length of stay in this manner on quality and health outcomes should be investigated.

Adult↗
PubMed2003

Denials of reimbursement for hospital care.

Much of the negative perception of managed care focuses on fear of denials of certification for reimbursement. This study examined more than 50,000 concurrent utilization reviews completed over a four-year period (1998-2001) at a large teaching hospital. The results showed a denial rate of less than 1.5% of all patients reviewed, higher denial rates among certain clinical services, higher rates of reviews among certain services only partially explained by volume of admissions, and a lack of patient criteria to receive care in the inpatient setting as the most frequent reason given for denial.

Concurrent Review↗
PubMedDate not supplied

Clinical and fiscal outcomes of utilization review.

Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.

Case Management↗
PubMed1990

Proposed criteria for independent peer reviewers.

Because of the complexity of craniomandibular claims, it is difficult for insurance adjusters to keep up with all of the advances and techniques regarding craniomandibular disorders. Insurance companies have found that they can process claims more quickly and economize by having claims reviewed. Because of this, independent insurance reviews have become routine for TMJ claims. Many practitioners contend that the current review system appears to be lacking in impartiality, criteria for reviewers, and standardized fees for various geographical locations. The author offers suggestions for objective reviews that ensure the use of qualified and responsible reviewers. Setting guidelines for reviewers will bring about more equitable reviews and assist in dismantling the confusion surrounding head and neck claims.

Humans↗