Utilization Review

Patient advocates who care…

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We understand that Utilization Review is much more than having payor knowledge and understanding of medical necessity criteria. Our team consists of dedicated advocates who care about each patient and their need for treatment. We are willing to go the extra mile, being their voice during a vitally delicate and often desperate time.

Our efforts are backed with the belief that every client deserves a chance at recovery and that journey typically begins with treatment.

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Advocating for our clients - Our Utilization Review Team is dedicated to ensuring that your clients receive the necessary coverage for their medical or behavioral health needs. Well trained and experienced in securing the highest level of care for as long as possible within the guidelines set by payers based on the medical necessity criteria. From admission through discharge, you can count on our knowledgeable and committed staff to advocate for your clients, holding the carriers accountable to fulfill their commitment to their customers' well-being.

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Partnering with your clinical team – Your team will have access to an expert utilization review professional who will seamlessly integrate with your clinical team by understanding the ins and outs of your program, clinical goals and structure to better help us align the carriers with the clinical recommendations. This ensures continuity of care throughout your client's treatment journey. By entrusting us with communication and authorization tasks, your clinical staff can focus entirely on patient care, free from the complexities of managed care. Having an assigned UR Representative prevents unnecessary gaps or misunderstandings of treatment team planning and goals.

In depth training, insight and education - In addition to securing authorizations, your dedicated utilization review professional will offer insights and support in navigating the intricacies of the carrier’s medical necessity criteria. From the onboarding overview and initial trainings to routine follow ups and check-ins, our team is here to help guide and educate your team members on appropriate medical necessity criteria and to provide detailed feedback on what is needed to justify continued care. Our established process is designed to increase the approval of services with proven results.

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Communication is still key – Similar to our VOB department, we will create a dedicated email distribution group with all necessary team members included which will serve as our primary form of communication. Each morning your team will receive a detailed overview of all new admission pre-certifications, concurrent reviews due and any pending reviews with detailed updates. Communicating off the morning email thread keeps all UR requests organized and easy to track. For those instances where an email is not being responded to or may have been overlooked, our team will reach out by phone to your designated point of contact to ensure reviews are being completed timely.

With Integrity – It is vitally important that your UR Team remains compliant and committed to moral integrity. Aside from the moral issue of providing dishonest quality of work, this can lead to very consequential and undesirable outcomes that may be unforeseen such as a facility being flagged or audited causing financial distress or inability to continue to provide services. Our UR Team is carefully vetted for moral integrity and QA remains one of our highest priorities.