Utilization Review (UR) is the process insurance companies use to approve, authorize or decline services. The purpose of the Utilization Review process is to screen and approve the “least-restrictive” clinical services on a per case basis. The reason insurance carriers use this process is to standardize approval criteria in order to only pay for services deemed medically necessary during this process. Additionally, Utilization Review helps prevent fraud, abuse, and The Waste of funds on unneeded services.
Any behavioral healthcare organization that works with insurance should realize that Utilization Review is one of the most critical aspects of obtaining payment. Quality Utilization Review and Management is the starting point from which the financial health of a healthcare organization is derived. Often overlooked or disregarded, improper and/or poorly managed UR limits profitability as well as a client’s length of and access to treatment.
We believe that no one can fight harder for your clients and their families than your own staff. Facility staff have first-hand knowledge of clients’ clinical cases, ongoing struggles, successes, long-term treatment goals and plans, and symptoms that meet medical necessity criteria. Because of this, AVA offers our depth of experience to assist you with in-house hiring, training and/or development of top-notch Utilization Review professionals from within your current staff.
For facilities that are not able to offer in-house Utilization Review, AVA provides an outsourced solution for an organization’s UR needs. We surpass our competitors by focusing on communication with facilities intake/admissions teams to develop a full medical and clinical picture of the client’s case prior to and upon intake. Upon intake, AVA’s UR team is able to frame the best argument for each and every client. This level of service and attention to detail is unparalleled. Our trained professionals are available to effectively manage this process for you.