A concurrent review in healthcare is a systematic check performed by insurance companies or other payers to manage costs and ensure patients receive appropriate treatment while they are still admitted to a facility. This mechanism confirms that the patient’s current hospital stay or ongoing care remains medically necessary. The process occurs throughout the duration of an inpatient admission, serving as a continuous assessment of the services being delivered. It is a component of the system used to balance high-quality patient care with the responsible use of healthcare resources.
What Concurrent Review Means
Concurrent review is a specific type of utilization review (UR), which evaluates the medical necessity, appropriateness, and efficiency of healthcare services. It distinguishes itself by taking place while the patient is actively receiving care, typically during a stay in an acute care hospital or a skilled nursing facility. The primary aim is to monitor the patient’s status in real-time to prevent unnecessarily long hospitalizations or the delivery of non-essential services.
This process contrasts with other forms of utilization management. Prospective review (pre-authorization) happens before treatment begins to determine coverage. Retrospective review occurs after the patient has been discharged, often to audit the care provided and verify billing accuracy.
By operating during the patient’s stay, concurrent review ensures that the initial approval for admission remains valid as the patient’s medical condition evolves. It acts as an ongoing checkpoint, focusing on whether the patient continues to require the intensive level of care provided by an inpatient setting. This evaluation helps streamline the care path, promoting efficiency and supporting timely discharge planning.
How the Review Process Works
The concurrent review process begins shortly after a patient is admitted, often on the first business day following the hospital’s notification to the payer. The review is conducted by a clinical professional, typically a registered nurse employed by the insurance company or a third-party utilization management firm. This reviewer communicates the patient’s status to the payer’s medical management team.
The reviewer obtains clinical information directly from the hospital’s care coordination team or the patient’s medical record. They examine various sources of documentation, including physician orders, daily progress notes, nursing assessments, and diagnostic test results. This data exchange is periodic, with the frequency depending on the patient’s condition and the length of the approved stay.
If the initial authorized length of stay is nearing its end, the hospital must submit updated clinical documentation to request an extension. Communication between the payer and the provider is ongoing and time-sensitive. Each time an extension is granted, a new review date is assigned to ensure continuous oversight of the patient’s need for continued acute care.
Assessing Medical Necessity
The core function of the concurrent review is to determine the medical necessity of the patient’s continued stay at the acute level of care. This determination is based on standardized, evidence-based criteria. Reviewers utilize nationally recognized guidelines, such as InterQual or Milliman Care Guidelines (MCG), to objectively evaluate the clinical situation.
These criteria compare the patient’s clinical status against specific benchmarks that define the need for an inpatient setting. The patient’s severity of illness must justify the hospital stay, meaning their condition requires monitoring or intervention only available in an acute care setting. Simultaneously, the intensity of service being provided must be appropriate for that setting, such as continuous intravenous medication or specialized monitoring.
If the patient’s condition has improved, the payer may determine that a lower level of care is more appropriate. The review process looks for signs that the patient could be safely treated in a less intensive environment, such as a skilled nursing facility, rehabilitation center, or at home with support. The goal is to ensure the patient is receiving the right care in the least restrictive and most appropriate setting.
Results and Next Steps
The concurrent review process yields one of two primary outcomes regarding the patient’s continued stay. The first is an approval, meaning the clinical documentation supports the need for further acute care, and the payer authorizes an extension for additional days. This decision is communicated to the hospital, and the patient’s treatment continues as planned.
The second outcome is a denial of continued stay, also known as an adverse determination, where the reviewer finds that the acute level of care is no longer medically necessary. This means the payer will not reimburse the hospital for any days beyond the last approved date, usually because the patient no longer meets the criteria for inpatient admission.
Upon receiving a denial, the hospital’s utilization management team often initiates a formal process of reconsideration or appeal. This may involve a Peer-to-Peer review, where the attending physician speaks directly with a medical director from the insurance company to discuss the clinical justification. If the denial is upheld, the focus shifts to discharge planning to transition the patient to the next appropriate level of care.