By Jordan G Roberts, PA-C

Optimize Your Clinical Efficiency and Spend Less Time on the Phone with Utilization Review

Love them or hate them, insurance companies are a major part of life for healthcare providers. You may feel that they are intentionally making your life more difficult, but the truth is that every move they make has been carefully considered to increase their chances of achieving favorable business outcomes.

This may not be too comforting; it may, in fact, be more irksome to some. But knowing how and why bureaucracy has influenced healthcare can help you do something about it. It may help you think more clearly when you feel that you or your patient has been personally targeted by a denial letter.

Of course, we know that many plans are following pre-approved guidelines that dictate whether or not they’ll pay for a study or lab test you’ve ordered. And most of the time, claims that are initially denies are reversed with just a little more clinical information.

Therefore, there are techniques and processes you can develop to make your life easier in this respect. The first part is optimizing your clinical documentation so that you can avoid this time-intensive problem altogether.

If – or when – a denial rears its dreadful face sheet on your fax machine, despite your best efforts, you have another option. This is the successful utilization review, otherwise known as the ‘peer-to-peer.’ If you aren’t winning the vast majority of these, or if you find yourself doing more of these than you’d like, this article is for you.

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Jordan G Roberts, PA-C helps medical education companies create and distribute the best medical education around. He helps students and clinicians improve their clinical game by using his background in neuroscience to teach simple ways to learn complex medical topics. He is a published researcher, national speaker, and medical writer. He can be found at Modern MedEd where he promotes clinical updates, medical writing, and medical education.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.