Ensuring reporting mandates and regulations are met accurately and on time
Understanding Utilization Reviews
Medical Consultants Network is a URAC-accredited Independent Review Organization (IRO); our independent review specialists provide specialty-matched, unbiased Utilization Review determinations which meet all URAC, state, and federal mandates within appropriate time frames.
Utilization Reviews address three main areas of concern on a treatment or type of care:
- The medical necessity or appropriateness of care
- Whether the care is experimental or investigational in nature, and if so, whether a particular plan would cover the type of care under review
- Administrative reviews / legal and clinical interpretations of medical policy and contract language and eligibility
These are common prompts to warrant ordering a Utilization Review:
- Retrospective considerations, which are completed after services (including outpatient procedures and services) have been provided to the patient.
- Concurrent (“Continued Stay”) Reviews conducted during a patient’s hospital stay or course of treatment (including outpatient procedures and services).
- Prospective (“Pre-Certification” or “Prior Authorization”) Reviews, conducted prior to a patient’s admission or course of treatment (includes outpatient procedures and services).
When a patient is seeking or has received health care, there are several points during the process at which a utilization review could be requested, and reviews are requested by many different types of entities. Because of this, MCN, as an accredited IRO, adheres to strict conflict of interest and privacy policies. Independent Utilization Reviews generally either assist health plans/insurers in determining whether a specific plan offers coverage for certain treatments and procedures, level of care, or other administrative issues such as legal and clinical interpretations of medical policy and contract language eligibility.
One type of Utilization Review, the External Review, is requested by the patient when their plan does not cover the treatment in question. Specifically, External Reviews are independent, third party utilization reviews requested by patients when internal reviews have determined that a particular health plan does not cover the cost of a particular treatment or type of care. Many aspects of External Reviews are strictly governed by the federal government under the Patient Protection and Affordability Care Act (PPACA), or through individual state laws. Determinations made in an external review are final and legally binding. As a URAC-accredited IRO with national reach, MCN is uniquely equipped to comply with both federal and state regulations regarding the external review process.
MCN also provides Formulary Exception Reviews, which address whether a formulary drug that is not currently on a claimant's benefit list is medically necessary and eligible for coverage by the insurer.