Utilization Review: What is UR?

There are lots of different elements of putting together an addiction treatment plan, with the utilization review being a key part of it. A utilization review is a process whereby a care plan is submitted by a clinician (or a Utilization Review team, which is highly recommended for a treatment program) to a patient’s insurance company, and then it is reviewed for necessity, determining whether or not the insurer is going to pay for the care. Read on to discover everything you need to know about utilization reviews.

What is Utilization Review?

A utilization review manager will work closely with payers, including insurance businesses to make sure there is fair reimbursement to the facility for the critical services that are being performed. While not always being on the opposite side, insurance firms want to lower payouts while treatment centers want to make sure their client gets all of the time that is required for their recovery. 

While utilization review managers do not necessarily need to be addiction experts, having first-hand experience and knowledge of addiction can be incredibly helpful when communicating with insurance businesses.

The reason for this is because treatment for addiction disorders is an extremely fluid process, which can sometimes be complicated and often overwhelming for those who do not have experience in the industry.  

Being able to talk with their counterparts at an insurance firm from a place of understanding and knowledge as it relates to the client is of excellent value. Moreover, an effective utilization review professional can optimize the number of days that the patient stays in the treatment program, therefore, giving them a much better chance of avoiding relapse once they have completed their treatment.

What will a utilization review expert do?

Usually, the utilization review employee will spend a considerable amount of time speaking with the representative at the insurance firm, talking with them about the circumstances of the client, advocating for their continued treatment.

Aside from this, the utilization review team is going to work closely alongside the clinician to understand the circumstances of the client and what is going to be required to achieve the very best outcomes from the treatment. 

HIPPA and documentation pertaining to the utilization review

While utilization review experts are not on the clinical side of the addiction treatment, they are still going to be in contact with confidential and private information. Because of this, regulations and laws governing HIPAA are also going to apply to the utilization review.

Peaks Recovery and their experienced UR Team

Here at Peaks Recovery, our utilization review team has plenty of experience and will do everything in their power to make sure your treatment is optimized. If you would like to find out more about how we can help you with your addiction treatment or if you have any queries about our utilization review team, please do not hesitate to contact us for more information.