Utilization Review Workflow Overview

The U/R Work Center allows users to keep track of U/R plans that need to be obtained or updated. Staying on top of authorizations is important for maximizing collections and minimizing the time between treatment and reimbursement. Use the tracking, organization, and recording features in AveaOffice to streamline the U/R process.

Workflow

The U/R workflow begins when a patient is admitted. The patient will appear in the Management Center > Organization Dashboard under the Patients Newly Admitted tile. Use this and the other tiles to review what work needs to be completed. Clicking into this tile navigates to the U/R Work Center and sorts for patients with an Episode U/R Status set to No U/R Plan. The Patients U/R Incomplete / Expired tile sorts for patients with an Episode U/R Status of Expired. The Patients U/R Expiring Soon sorts for patients with an Episode U/R Status of Expiring Soon.

Patients Newly Admitted

Navigates to: Work Center > VOB and U/R > U/R. Sorts for patients with an Episode U/R Status set to No U/R Plan.

Indicates: There are patients without any utilization plans created.

Recommendation:

1. Use the arrows to the right of the Follow-Up column heading to bring the most overdue patients to the top.
2. If the patient needs authorization, follow-up with the payer. Create a new utilization plan from the Work Center and update the follow up date. The follow-up date should reflect when the patient’s U/R will require additional action. For help creating a U/R plan please see, How to Create a U/R Plan.
3. For patients that do not require U/R, update the follow-up date. The follow-up date should reflect when the patient’s record will need to be updated. When a patient will never require U/R, it is often useful to set the follow-up date as the patient’s anticipated discharge date. Use the follow-up date as a reminder to audit patient records and charts, ensuring that level of care criteria is still being met.
4. If the patient is no longer in treatment, click Update Admit/Discharge Status and add a discharge status and date. This will make the Organization Dashboard more accurate by removing the patient from the U/R Work Center.

Patients U/R Incomplete Expired

Navigates to: Work Center > VOB and U/R > U/R. Sorts for patients with an Episode U/R Status set to Expired.

Indicates: There are patients with previous authorization plans, but not one that covers the current date. This could mean that follow-up needs to happen, or the patient needs to be discharged.

Recommendation:

1. Use the arrows to the right of the Follow-Up column heading to bring the most overdue patients to the top.
2. If the patient needs more authorization, follow-up with the payer. Create a new utilization plan from the Work Center and update the follow up date. The follow-up date should reflect when the patient’s U/R will require additional action. For help creating a U/R plan please see, How to Create a U/R Plan.
3. For patients that do not require additional U/R, update the follow-up date. The follow-up date should reflect when the patient’s record will need to be updated. If the patient is stepping down and will no longer require U/R, it is often useful to set the follow-up date as the patient’s anticipated discharge date. Use the follow-up date as a reminder to audit patient records and charts, ensuring that level of care criteria is still being met.
4. If the patient is no longer in treatment, click Update Admit/Discharge Status and add a discharge status and date. This will make the Organization Dashboard more accurate by removing the patient from the U/R Work Center.

Patient U/R Expiring Soon 

Takes you to the Work Center: Work Center > VOB and U/R > U/R. Sorts for patients with an Episode U/R Status set to Expiring Soon.

Indicates: There are patients with authorization plans nearing the end date. This could mean that follow-up needs to happen, or the patient needs to be discharged.

Recommendation:

1. Use the arrows to the right of the Follow-Up column heading to bring the most overdue patients to the top.
2. If the patient needs more authorization, follow-up with the payer. Create a new utilization plan from the Work Center and update the follow up date. The follow-up date should reflect when the patient’s U/R will require additional action. For help creating a U/R plan please see, How to Create a U/R Plan.
3. For patients that do not require additional U/R, update the follow-up date. The follow-up date should reflect when the patient’s record will need to be updated. If the patient is stepping down and will no longer require U/R, it is often useful to set the follow-up date as the patient’s anticipated discharge date. Use the follow-up date as a reminder to audit patient records and charts, ensuring that level of care criteria is still being met.
4. If the patient is no longer in treatment, click Update Admit/Discharge Status and add a discharge status and date. This will make the Organization Dashboard more accurate by removing the patient from the U/R Work Center.

U/R Work Center

The information in U/R Plans directly correlates to the U/R Work Center. The Work Center can be used to assign follow-up, organize workflow, and keep track of utilization plans nearing an end date.  Use the filter options to zero in on patients that require attention.

Filter Options:

• Case Manager: All, Assigned to Me, Unassigned.
• Practice
• Facility
• Rendering Provider
• Payer
• Episode U/R Status: All, No U/R Plan, Active, Expiring Soon, Expired.

Available Actions:

Bulk Assign Case Managers: Assign multiple patients to a user for follow up.

Remove from Work Center: Use this option to manually remove patient from the U/R Work Center. Patients are automatically removed from the Work Center when they’re discharged. To ensure that patients are being discharged, best practice is to avoid manually removing patients using this feature. Instead, update follow-up dates to optimize tracking.

Download as Excel File: Use this to copy the U/R Work Center into Excel. 

Create Utilization Plan: Allows the user to add another U/R plan for the selected patient. Adding a U/R plan here creates a new entry in the patient’s Scheduling and Utilization tab. For help creating a U/R plan please see, How to Create a U/R Plan.

Edit Follow-Up Details: Use this to individually update the assigned case manager, follow-up date, and Insurance Care Manager contact information for a single patient.

Update Admit/Discharge Status: Navigates to the patient’s Admit/Discharge tab. When a patient is discharged, they are removed from the U/R Work Center.

Columns:

All columns can be ordered by using the arrows to the right of the column header. 

• Follow-Up: Manually set from this screen, or in the patient’s U/R tab. This date represents when additional action is needed to review and update the patient’s U/R plan, records, and/or discharge status. For patients that do not require U/R, or no longer require U/R, use Follow-Up dates as a reminder to audit patient records and charts, ensuring that level of care criteria is still being met.
• Case Manager: The user responsible for updating U/R and/or discharge information. Manually set from this screen, or in the patient’s U/R tab. 
• Patient
• Practice
• Current Primary Payer
• Service
• End Date: The end date of the authorization.
• Facility
• Rendering Provider
• Units
• Remaining Units: Number of unused units under the U/R plan.
• Review Type: None Selected, Initial Review, Concurrent Review, Peer Review, Expedited/Urgent Appeal.
• Auth Status: Authorized, Denied, Not Required, Pending*, Required – Not Obtained.
• Recent Service: Shows the end date of the most recently expired U/R plan.
  *Pending is the ONLY Auth Status that will prevent claim submission. Pending U/R plans must have the status changed before claims under that plan can be submitted.