How do Case Managers Support the Utilization Review Process?

When it comes to managing costs while ensuring quality patient care, the utilization review (UR) process is a requirement. But who makes sure this process runs smoothly? This is where Case Managers come in. In this blog, we’ll explain and show how their role is essential in establishing a seamless UR process.

What Is Utilization Review?

Utilization review is a systematic process used by insurance companies, healthcare providers, and third-party administrators to evaluate the necessity and appropriateness of medical treatments. If you want a full refresher on UR and its processes, click here.

Case managers serve as the bridge between medical providers, patients, and insurance companies.

The Role of Case Managers in Utilization Review

Case managers serve as the bridge between medical providers, patients, and insurance companies. Here’s how they do it:

1. Gathering and Analyzing Medical Information

Case managers collect and review medical records, test results, and physician recommendations to ensure the requested treatment aligns with medical guidelines (National Association of Healthcare Advocacy Consultants [NAHAC], 2022).

2. Ensuring Compliance with Guidelines and Policies

It’s important to ensure that all treatment recommendations comply with insurance policies, state regulations, and evidence-based guidelines, such as those from the American Medical Association (AMA, 2023). Without them, the risk of non-compliance skyrockets, leading to denied claims and delayed treatments.

3. Facilitating Communication Between Stakeholders

Case managers work with physicians, patients, and insurers to clarify treatment plans and address concerns handling tasks that adjusters lack time or medical expertise to handle.

4. Advocating for the Patient

Ultimately, case managers are patient advocates. If a treatment is denied, case managers can assist in the appeal process, providing additional documentation and working to overturn unjust denials (AHRQ, 2023).

The Role of Adjusters in UR:

Adjusters handle a large case load and many times are understaffed due to the nature of this role. As an adjuster, although you could handle some of these tasks yourself, case managers are better versed in the medical side of claims, making the process smoother and more efficient.

• Lack of specialized medical knowledge – While adjusters have general medical knowledge, they don’t have the same level of expertise as case managers.
• Heavy caseloads – They don’t have the bandwidth or time to dedicate to multiple, deep medical reviews.
• Utilization review is a specialized process – Not all adjusters are trained to handle it properly.
• Compliance risks – States have different rules on medical treatment approvals, and a specialized case manager helps keep the claim compliant.

The Backbone of Case Management

Case Managers ensure that medical necessity decisions are made based on facts and educate adjusters on any medical terms or conditions.
Their ability to analyze, communicate, and advocate makes them indispensable in the world of claims management and Workers’ Compensation.

References

• Agency for Healthcare Research and Quality. (2023). Utilization review in healthcare: Best practices and guidelines. AHRQ Publications.
• American Medical Association. (2023). Medical necessity and utilization review standards. AMA Press.
• Council for Case Management Certification. (2023). The role of case managers in modern healthcare. CCMC Reports.
• National Association of Healthcare Advocacy Consultants. (2022). Optimizing case management for cost-effective care. NAHAC Insights.