Utilization Review: high-yield desk drill

The rule

Approve when written criteria are met. Refer coverage doubt. Do not issue the denial.

Next step

If the finding is not documented, write that it is absent and pend or refer.

Never miss

• Prospective, concurrent, and retrospective packets differ.
• Criteria products are named as concepts only.
• A scheduling comment is not clinical evidence.
• Peer-to-peer needs the packet, the question, and the treating clinician.
• The physician or other qualified practitioner decides inpatient versus outpatient. The desk reviewer does not.
• A status packet starts with the order for inpatient admission.
• When later entries conflict with the order, quote them with author and time. Name the order as the anchor. Do not strip the losing version.
• A committee send is the question in one sentence, every document you read with source and date, and only the pages the question turns on.

Traps

• Putting a nurse's name on a denial.
• Assuming a finding because the stay is long.
• Skipping the note when the portal is slow.
• Letting the payer contact or the review committee decide admission status.
• Sending every historical volume so the committee never has to request more.

Shortcuts

• Today's update for concurrent review.
• Physician reviewer for doubt.
• Keep the trail.

Terms

• Concurrent. Review while the stay or service is still underway.
• Retrospective. Review after discharge or claim submission.
• Peer-to-peer. Treating clinician speaks with the plan clinician. You schedule and send the packet.
• Admission order. The inpatient admission order the status packet starts from. Without it there is no packet.
• Amendment marking. A later note that actually changes the order. A later observation line without that marking is not an amendment.

Memory hooks

• APPROVE-OR-REFER. The only two nurse moves UM scope.