UR/BR Connectivity and Effectiveness


Utilization Review (UR) and Bill Review (BR) are two key components in the managed care industry that must work together effectively if a program is truly going to flourish. For years so many organizations struggle connecting these two areas effectively. Have you had situations before in the industry where a service or procedure was denied from the UR department but for some reason the bill still ended up being paid for that service that was preveiously denied by UR? Based on my experience working in the industry for more than 23 years I am going to assume the answer is yes to this question.

Integrating Utilization Review and treatment authorizations/non-authorizations with Bill Review does appear to be one of the more challenging items that managed care programs, claims adminstrators and Bill Review programs have to be conscious of today. In the managed care arena we have 17 jurisdictions that are specifically UR jurisdictions and those specific UR rules are unique from jurisdiction to jurisdiction. Outside of the UR states we also have jurisdictions nationally that don't require UR, but have pre-authorization requirements, treatment rules and case Management guidelines that have to be documented by the Nurse Case Manager or Claims Administrator to ensure the medical management of the case is being documented but also actively communicating with Bill Review. This unique marriage of medical data with the bill review piece can impact medical outcomes and medical providers billing practices if done effectively from a national perspective.

At EK Health we have been able to integrate decisions from UR to BR which is allowed our customers to see 8 - 21% more savings beyond the normal bill review savings from a national perspective. We have worked extremely hard over the last ten years with our technology company (DataCare) to ensure that the treatment being billed by medical providers should be paid is reasonable and acceptable within jurisdictional guidelines. State to state treatment guidelines and utilization rules could change each year and ensuring your Claims or Managed Care teams are aware of those changes are very critical in the success of integrating a strong UR/BR model.

In November 2016, EK Health and DataCare finished expanding our Enforcer model beyond the 17 UR states and we are now effectively able to capture treatment requirements natioanlly. We have diligently reviewed the compliance regulations to understand the treatment regulations, pre-authorization rules and utilization rules for all jurisdictions and ensured those rules would apply for all medical bills and authorization decisions from a case management perspective. As we head into 2017 we are excited about the inovaton that we have accomplished and continue our pursuit to advance automation with bill review. Through automation we have significantly reduced the potential of human error when integrating treatment authorizations/ non authorizations with bill review and have optimized savings results and outcomes.


Jeff Jahnke, Executive Director of Bill Review