Hansei Solutions is committed to providing utilization review services that assess the medical necessity, appropriateness, and efficiency of healthcare services to ensure they meet quality and cost standards, all while ensuring your clients receive the care and coverage they deserve.
Hansei Solutions’ utilization review services prioritize you and your client’s best interests, promoting the placement of individuals in the least restrictive and least resource-intensive level of care necessary to meet their needs. These evidence-based methods are tailored to each provider’s unique participation criteria and standards, ensuring high-quality care for all demographics and diagnoses.
Our trained professionals handle all communication with payers regarding authorizations, allowing your clinical staff to focus on treating your clients without the distraction of managed care. We aim to obtain insurance coverage for your client’s entire health plan at the clinically indicated level of care designated by your treatment team, from initial payer approval to concurrent service reviews, appeals, and post-service reviews.
According to data from the Organization for Economic Cooperation and Development (OECD), the United States spends nearly twice as much per capita on healthcare as the average of other developed countries. Utilization review plays a critical role in both medical and behavioral healthcare, ensuring low costs and maximum revenue. Its importance lies in three key areas.
Our utilization review services streamline the medical decision-making process and surpass accreditation and state requirements, helping save valuable administrative and response time. Hansei Solutions’ utilization review services include:
Utilization management relies heavily on the review process, which encompasses three distinct types: prospective, concurrent, and retrospective. Each type involves a unique utilization review process flowchart with different use cases.
Prospective review is conducted before treatment to evaluate the procedure’s necessity and eliminate duplicate treatments. Other names for prospective review include prior authorization pre-service review, pre-procedure review, or pre-admission certification.
This occurs while treatment is in progress to monitor the patient’s progress and resource utilization. This type is critical as insurance companies can deny coverage later on. Reviewers may also halt treatment prematurely or discharge patients earlier than anticipated. A concurrent review involves three significant areas: discharge planning, care coordination, and care transition.
This is performed after treatment completion and focuses on effectiveness and appropriateness. The most important use of retrospective reviews is with claims, as they can be used to verify the accuracy of reimbursements and challenge denied claims.
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