Concurrent review is a process of exploitation of review that occurs when a patient is actively receiving treatment (e.g. during hospitalization). It evaluates the medical necessity and appropriateness of ongoing medical services to ensure that patients receive the right level of care at the right time at the right time.
Given its importance to leveraging managers, concurrent reviews are significantly less focused than previous authorized reviews. Although prior authorization makes many(Opens in new window) Headline News(Opens in new window) In the past year, concurrent reviews have not been made. However, mistakes in both processes put the hospital at risk of not being paid, which could lead to higher costs to patients.
A closer look shows that as hospitals and health systems carefully examine their utilization review practices, the danger of concurrent review is ignored.
Utilization Review: Overview
Utilization Review (UR) involves the collection of information during and after treatment at the admission site and in patient care to assess medical necessity and the appropriateness of care related to the desired outcome.
You are composed of three stages:
- Prior authorization for reviewSometimes called the expected authorization review, it occurs before treatment. These comments ensure that the requested care is medically appropriate.
- Concurrent review. In addition to monitoring ongoing medical services for ongoing patients, the simultaneous review involves care coordination between multidisciplinary teams, disease management, discharge planning, and transition to other nursing facilities. This process helps prevent unnecessary or prolonged care, improve patient outcomes and manage medical expenses. Unlike previous authorizations obtained before treatment begins, concurrent authorizations are required during treatment to ensure that they remain medically necessary and covered.
- Retrospective Comments Occurs after treatment to assess the success of the care provided and to determine if the billing code is correct. In addition, through a retrospective review, utilization management guidelines are regularly updated based on treatment efficiency. Then, future requirements for these treatments are more likely to be based on previous successful approvals. This review process is particularly important as new treatments and drugs enter the market.
Concurrent and retrospective reviews occur behind the scenes, so patients may not be aware that these processes are happening. Although concurrent and retrospective comments may not directly affect patient costs, they can affect payments received by the care provided by the hospital to the patient.
Why is prior authorization the spotlight?
Many headlines emerged when the Centers for Medicare and Medicaid Services (CMS) prioritized fixing it. Last year, CMS established a January 2027 deadline, within which affected payers must implement a pre-authorization API to facilitate electronic pre-authorization requests and responses, with an emphasis on simplifying processes and improving interoperability.
The CMS “Final Rules” will require affected payers to send a prior authorization decision within 72 hours with an emergency request, and seven calendar days for non-emergency requests for medical programs and services. Compared with concurrent review The only one Review and payment of claims filed during the previous authorization review process.
Furthermore, we are all patients and therefore have a better understanding of the previous authorization process. For example, before scheduling a surgery or supplementing a prescription, it is often possible to realize when insurance is authorized, and even estimate the balance bill in advance to the patient. Since concurrent authorization is done behind the scenes, the same spotlight is not captured at all.
Why is concurrent review underestimated, but needs improvement now
There are many reasons why the concurrent review process requires attention as an integral reason for the financial crisis affecting the healthcare industry and patients.
- deny. Each rejection is processed according to the specific contractual terms between each payer partner and the relevant hospital. Concurrent rejection, peer-to-party and formal appeal proceedings can require each payer to be different. However, many case management directors may not know what constitutes these contracts.
Medical necessity denial poses $2.5 billion problem(Opens in new window) For medical organizations, every year. Due to the treatment, treatment and/or misunderstanding of how the patient should be treated as a medically necessary treatment, treatment and/or misunderstanding, each provider (average annual rejection) has approximately $5 million in rejection.
- They provide your manager with an opportunity to focus on strategically. Since concurrent reviews are conducted in real time, the benefits are not immediately visible compared to previous authorized or retrospective reviews. This shows that this is just a misleading view that it is an administrative barrier. Instead, concurrent reviews provide strategic opportunities to optimize care delivery and coordination.
How expensive is this question? Avoidable delays in care account for approximately 25% of the average length of hospital stay (4.2 days and 1.2 days), equivalent to 10.8 million avoidable hospital stays. There are 29,590 complete hospital beds throughout the year(Opens in new window). The average room price is $2,873 a day, so you can save $1.5 billion a year by simply reducing the avoidable days by 5%.
- By continuously evaluating the medical necessity of ongoing treatments, while proceeding reviews minimize patients’ delays as they have received care, creating more seamless transitions to care. This ensures timely access to critical treatments while still allowing the payer to manage the expenses responsibly. While it may not directly affect the immediate cost of patients, it simplifies the provider’s process and allows them to focus on providing quality care(Opens in new window).
How important is a more seamless transition to care? Some studies have shown that up to one in five patients suffer from adverse events within two weeks of discharge, many of whom could have been relieved or prevented. The reported cost of medical errors is broad, with some experts estimating $20 billion a year, while others spending only $357 to $45 billion a year on infections obtained by hospitals(Opens in new window).
in conclusion
Comments made simultaneously are key in the care continuum, not because it is not important, but because its benefits are often behind the scenes. With increasing financial pressure and a focus on value-based care, investing in a smarter, more integrated concurrent review process is not only necessary, it is urgent.
Photo: Eugene Mymrin, Getty Images
Michelle Wyatt, DNP, MSN, RN, CMS(Opens in new window)is the senior director of clinical best practices at Xsolis(Opens in new window) With over 20 years of healthcare experience, recently served as Director of Case Management and Utilization Review at HCA Healthcare. Prior to this, she served as Director of Utilization Management at Vanderbilt University Medical Center and received her PhD in Nursing Management from Vanderbilt University School of Nursing. She began her career using reviews to execute Care Management reviews for TN General Nursing and currently oversees the XSOLIS clinical team that leads clients’ implementation.
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