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Care Request Review Types
Care requests can be reviewed before, during, or after the care is provided. The timing of a review can affect how you use Health Cloud to manage the process.
Prior Authorization Review
Prior authorization is a way to review non-emergency hospitalizations, outpatient surgery, skilled nursing and rehabilitation services, home care services, and some medical equipment. It's also referred to as prospective review, precertification, or preauthorization.
Prior authorization review is done before care is rendered to reduce unnecessary services. Prior authorization is likely in our example because the member is being referred for scheduled surgery as an outpatient.
Each health plan has one or more precertification lists, depending on the type of plan. Most lists include non-emergency hospitalizations, outpatient surgery, skilled nursing and rehabilitation services, home care services and some home medical equipment. The review and approval process involves determining whether the requested service is medically necessary.
Concurrent Review
Concurrent Review takes place while care is happening. It often takes the form of a decision on whether to continue a hospital stay. The focus of concurrent review is to ensure that the member is getting the right care in a timely and cost-effective way.
The first concurrent review often determines a plan for eventual discharge or transfer to rehabilitation, hospice, or nursing facilities. If our example member has surgery as an inpatient and complications arose, a doctor can recommend extending the hospital stay. In that case, concurrent review would come into play.
When a provider requests continued treatment, it's important to document the amount and types of therapy the member has already completed.
Retrospective Review
Retrospective review is conducted after the service has been completed. Emergency room care is often subject to retrospective review because there isn’t time for prior authorization review.
Retrospective review gives the payer organization the additional information to approve or deny payment for services already received. If our example member had been brought to the emergency room, this case can be a candidate for retrospective review.
Independent review organizations often conduct retrospective reviews. Reviewers look for evidence of appropriate health care, and compare the records to records of other members with the same condition.
