Utilization and review is a vital part of your medical billing. UR specialists obtain prior authorizations, complete concurrent reviews, and assist in discharge planning, to better assure that payment is received for services rendered. The UR specialist is there not only to advocate for your facility, but also for your client. Authorizations given by the case manager at the insurance company are necessary to make sure the client is receiving proper care for their stay, resulting in proper pay for you during treatment and after discharge. The UR specialist abides by ASAM guidelines, and relays the proper dimensions for your client.
Guidelines are as follows:
ASAM 1. UDS: last one and results; PAWS; Cravings; Last Use Date; Drug Dreams; Withdrawal Symptoms—severity of depression, anxiety and cravings
ASAM 2. Medical Conditions complicating treatment——Hepatitis C, Diabetes Mellitis, Hypertension, Cancer, ETC.
ASAM 3. Current Mental Status Exam—- worse they are being the better; Sleep pattern—worse better; Appetite—worse better; Trauma work undergoing or needed—worse better; Current medications taking—-any changes and complying? Anti-craving medication considered? If not using these then why? If yes, dosage and is the client compliant?
ASAM 4. Internally or Externally Motivated; Family Relationships currently. What stage of change is the client presently exhibiting in his initial evaluation?
ASAM 5. Relapse Risk potential: Low, medium or high and why is this client felt to be at that risk level?
ASAM 6. Recovery Environment; Lacks sponsor or support Network; Living conditions (Homeless?); Employment problems; Interpersonal & Family problems. Family sessions are very important with most, if not all, insurance companies.
Our extensive knowledge in UR, will assure proper length of stay for your clients, and proper payment for you.
A Utilization Review Specialist is the quality assurance expert of the medical world. While patients focus on their recovery, Utilization Review Specialists ensure that Doctors and Nurses choose only the best treatments for them. … As for medication, you want patients to receive only what they need.