Utilization Management

Precertification/Preauthorization — reviewing information prior to inpatient admission, or selected outpatient treatments or services, to determine medical necessity of the proposed treatment or admission.

Concurrent Review — determines the medical necessity of continued inpatient admission or treatment.

Retrospective Review — determines the medical necessity of care that has already been provided to a claimant.

Peer Review — a physician review to determine if a condition or injury is work related; this often assists in determining compensability of a worker’s compensation claim.

File Review and Bill Audit — Medical records are reviewed to ensure compliance with the worker’s compensation, liability, or other pertinent billing criteria for each state. The bills are then reviewed for relatedness and to ensure all charges are supported in the medical record.

Prescription drugs/pharmacy review — – Review of prescribed medications to determine medical necessity and appropriateness to treat the worker’s compensation claim. – Reviews may also address relatedness to the compensable work injury and provide recommendations for alternative medications/treatment options.