Utilization Review (UR) is a process used by health insurance payers to evaluate the appropriateness, efficiency, and medical necessity of healthcare services. This oversight helps manage costs and ensures patients receive care that aligns with established standards. Concurrent Review (CR) is a specific type of utilization management that occurs while a patient is actively receiving treatment, such as during a hospital admission. It is an ongoing evaluation conducted by the payer to monitor whether the current treatment setting remains appropriate for the patient’s condition.
Defining Concurrent Review and Its Timing
Concurrent review begins shortly after a patient is admitted to a hospital or starts an ongoing course of treatment, often within the first 24 to 72 hours. The process is conducted by licensed clinical personnel, such as registered nurses or physician advisors, who work for the health plan or a third-party review organization. Reviewers communicate with the hospital’s utilization management staff to obtain clinical updates and progress notes.
The review is repeated at scheduled intervals throughout the patient’s stay, and each successful review authorizes a specific number of additional days of coverage. The goal is to confirm that the patient continues to meet the criteria for the current level of care, such as an acute inpatient setting. If the patient’s condition improves, the reviewer works with the hospital to facilitate timely discharge or transition to a lower level of care.
Determining Medical Necessity
The concurrent review decision hinges on medical necessity, meaning the service must be reasonable and appropriate for the diagnosis or treatment of a patient’s condition. To make this determination, payers rely on standardized, evidence-based criteria developed by third-party organizations. The most widely used proprietary tools are InterQual and Milliman Care Guidelines (MCG).
These guidelines provide specific clinical benchmarks, such as lab values, vital signs, and required intensity of nursing care, that must be met to justify a continued acute stay. The hospital staff provides the patient’s updated clinical information, including progress notes and treatment plans, to the reviewer for comparison against the established criteria. If the patient’s condition no longer meets the severity of illness or intensity of service requirements, the reviewer may determine that the continued acute stay is not medically necessary.
Concurrent Review Versus Other Utilization Reviews
Concurrent review distinguishes itself from the two other main types of utilization review primarily through its timing. Prior Authorization, also known as prospective review, occurs entirely before a service is delivered, ensuring the care is approved for coverage ahead of time. This review is used for elective surgeries, expensive imaging, or high-cost medications.
Retrospective Review takes place after the patient has been discharged and the claim for services has been submitted. This review evaluates documentation to confirm that the care provided was medically necessary and billed correctly. Concurrent review monitors the progression of treatment in real-time, allowing for immediate intervention. Its unique position means it directly influences the ongoing length of stay and the level of care a patient receives while still admitted.
Adverse Determinations and the Appeals Process
If the reviewer determines that a patient no longer meets the criteria for the current level of care, the payer issues an adverse determination, which is a denial of continued coverage. This decision means the health plan will no longer cover the cost of the inpatient stay beyond a specific date. The hospital and the patient must be notified of this denial, including the specific reason and the criteria used.
Patients have the right to challenge this adverse determination through a formal appeals process. The first step is an internal appeal, where the patient or provider requests the health plan to reconsider its decision. For hospitalized patients, this appeal is handled on an expedited basis, with a decision rendered quickly due to the urgency of continued care. If the internal appeal is unsuccessful, the patient can pursue an external appeal, where an Independent Review Organization (IRO) reviews the case to make a binding coverage decision.