Utilization Review

Utilization Management is the process used to evaluate requested health care services and determine whether they are medically necessary. Under the supervision of our Medical Director, both inpatient and outpatient services are reviewed by a team of experienced nurses using nationally recognized, evidence-based criteria. MedCost also maintains a review panel of more than 90 physician consultants who are board certified and currently practicing in a wide variety of specialties. The MedCost Utilization Management program has been URAC accredited since 1994, which assures members of our compliance to federal and state standards for review procedures.

Inpatient Utilization
The ultimate goal of Inpatient Utilization Management is to insure that each patient gets the appropriate care at the appropriate location. Before any member is actually admitted to the hospital, MedCost should be notified for precertification. Our nurses will review the patient’s medical history to make sure the hospital stay is necessary. Once a patient is admitted, our nurses collaborate with the hospital discharge planner to develop a plan, expedite the discharge, and arrange for any services the patient will need after leaving the hospital.

Outpatient Utilization
Since many procedures that used to require a hospital stay now are done on an outpatient basis, our Outpatient Utilization Management provides a safeguard for members. As part of precertifying any outpatient surgical procedure, our clinicians evaluate patient history to ensure that other, more conservative measures have been exhausted. The goal of Outpatient Utilization Management is to reduce the number of unnecessary procedures while keeping the patient’s health and safety a top priority.

To improve efficiency, we have two programs available to our clients as part of Outpatient Utilization. The Comprehensive Outpatient Review program includes all elective outpatient surgical procedures done outside the doctor's office, including varicose vein treatment and MRI, CT, and PET scans. The Diagnostic Review option includes only review of MRI, CT, and PET scans. Changes in medical practice have led to overutilization of these diagnostic imaging procedures, and they continue to have a significant denial rate by our practicing physician review panel.

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