What are the most important metrics to track when evaluating a utilization review program?

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Utilization review (UR) is a process of evaluating the appropriateness, quality, and efficiency of health care services, procedures, and facilities. It is a key component of utilization management (UM), which aims to optimize health outcomes and reduce costs. As a case manager, you need to monitor and measure the performance of your UR program to ensure that it meets your goals and standards. But what are the most important metrics to track when evaluating a UR program? Here are some suggestions:

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Yvette Coley

Healthcare Administrator

1 Length of stay

Length of stay (LOS) is the number of days a patient spends in a hospital or other health care facility. It is a common indicator of the intensity and complexity of care, as well as the resource utilization and cost. By tracking LOS, you can assess how well your UR program is managing the admission, discharge, and transition of patients. You can also identify areas of improvement, such as reducing unnecessary or avoidable hospitalizations, preventing readmissions, and facilitating timely discharges.

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2 Denial rate

Denial rate is the percentage of claims or requests that are rejected by payers or reviewers for various reasons, such as lack of medical necessity, insufficient documentation, or non-compliance with policies and guidelines. It is a measure of the effectiveness and accuracy of your UR program, as well as the potential revenue loss and administrative burden. By tracking denial rate, you can evaluate how well your UR program is communicating and collaborating with payers and providers, ensuring compliance with criteria and standards, and resolving issues and appeals.

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3 Patient satisfaction

Patient satisfaction is the degree to which patients are happy and satisfied with the quality and outcome of their care, as well as their experience and interaction with the health care system. It is a measure of the patient-centeredness and value of your UR program, as well as the potential impact on loyalty and retention. By tracking patient satisfaction, you can assess how well your UR program is meeting the needs and expectations of patients, respecting their preferences and choices, and involving them in the decision-making process.

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Author Stephanie Shannon
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Remember the person you service is the most important factor in any equation. It’s how you treat people that counts no matter the situation it’s costs $0 to be kind. If you’re patient isn’t satisfied you shouldn’t be either. Going beyond the call of duty is what everyone should strive for no matter the economic status a person has. You should treat people how you want to be treated.

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4 Provider satisfaction

Provider satisfaction is the degree to which providers are happy and satisfied with the UR program, its processes and procedures, and its impact on their practice and performance. It is a measure of the provider engagement and alignment of your UR program, as well as the potential influence on quality and efficiency. By tracking provider satisfaction, you can evaluate how well your UR program is supporting and facilitating the delivery of care, providing feedback and education, and reducing barriers and hassles.

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Author Stephanie Shannon
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Make sure your service providers are happy with ask them how are things going. Listen to their feedback and put it as a top priority to try to implement what you’ve discovered. This way your providers will feel valued and confident that you’re doing the best to accommodate their needs.

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5 Cost savings

Cost savings is the amount of money that is saved or avoided by implementing the UR program, compared to the baseline or alternative scenario. It is a measure of the financial benefit and return on investment of your UR program, as well as the potential contribution to the sustainability and competitiveness of the health care system. By tracking cost savings, you can quantify how well your UR program is reducing unnecessary or inappropriate services, optimizing resource allocation and utilization, and improving value and quality.

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Author Stephanie Shannon
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Make sure you’re frugal in your costs and that you’re not wasting time or resources. Time is something you can’t ever get back looking at ways to be cost effective is important in delivering quality services to your customers or clients. Spend time seeking ways to be more cost effective and then apply what is learned

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Yvette Coley

Healthcare Administrator
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CMS guidelines: Utilization Review (UR) and Utilization Management (UM) are critical components in the healthcare system, especially in ensuring compliance with Centers for Medicare & Medicaid Services (CMS) guidelines. Their appropriate use not only aligns with regulatory requirements but also enhances the quality and efficiency of healthcare delivery. Proper implementation of UR and UM helps healthcare organizations stay compliant with CMS regulations. This is crucial not only for receiving CMS funding but also for maintaining accreditation and avoiding legal and financial penalties. Data-Driven processes often involve collecting and analyzing data on healthcare services and outcomes, aligns with CMS.

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What are the most important metrics to track when evaluating a utilization review program?

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6

1 Length of stay

2 Denial rate

3 Patient satisfaction

4 Provider satisfaction

5 Cost savings

6 Here’s what else to consider

Case Management

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What are the most important metrics to track when evaluating a utilization review program?

1

2

3

4

5

6

1 Length of stay

2 Denial rate

3 Patient satisfaction

4 Provider satisfaction

5 Cost savings

6 Here’s what else to consider

Case Management

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