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TRUSTED FOR FOUR DECADES.
1. Prospective review
Occurs before the services are rendered.
• If the payer requires preauthorization, the request would trigger a prospective utilization review.
• A preadmission case manager should review scheduled surgical cases to determine appropriate level of care and ensure that there are no pre-op days not meeting medical necessity.
• Review National Coverage Determination to assure that the documentation in the record demonstrates that specific procedures are appropriate.
2. Concurrent review
Occurs while services are being rendered.
• If a provider requests hospital days beyond those approved, a concurrent review would be triggered.
• Medicare expects that case managers manage the medical necessity of its beneficiaries.
• DRG reimbursed cases should be reviewed for medical necessity.
• Episodes of care covered under a bundled payment arrangement should be reviewed.
• Case managers should conduct a review of all concurrent denials.
• Cases of unfunded and underfunded patients should be reviewed concurrently.
3. Retrospective review
Occurs after services have been rendered.
• Case managers should review cases when a short stay patient is admitted and discharged before a medical necessity review has been conducted.
• A denial is issued after a patient has been discharged.
Source: Case Management Concepts
Financial Disclosure: Author Mary Booth Thomas, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
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