It’s a great question, isn’t it? We would be willing to wager that if you were to ask 100 people from the insurance industry this question, you would receive 100 different responses.
One of the challenges that we are faced with when discussing Utilization Management (UM) is that terminology changes from State-to-State and from insurance company to insurance company.
For example:
- What CA calls ‘utilization review’, TX may call ‘pre-authorization’
- What TX calls ‘peer review’, IL may call ‘utilization review’
- What IL calls ‘medical file review’, FL may call ‘peer review’
- And so on, and so on…
Although we’re all using the same words, the meaning of the words vary, making discussions in the world of UM very confusing at times.
At CID we feel it’s time to bring order to the chaos. We’d like to share the meanings of the words we use on this website to describe the services we offer, in order to help ensure that we are all speaking the same language.
Utilization Management
A general term which involves reviewing requests for authorization submitted by treating physicians in order to make a determination of medical necessity. This includes initial reviews, peer reviews, medical file reviews, peer to peer and the CID automated approval program.
Initial Review
A general term for the initial review of requests for authorization in order to make a determination of medical necessity, wherein the request may be approved if consistent with evidence based guidelines, but may not be denied.
Peer Review
A general term for the physician review of requests for authorization in order to make a determination of medical necessity, wherein the request may be approved, modified or denied.
Medical File Review
A general term for the review of the patient’s complete or near-complete, medical file in order to respond to questions posed by the claims staff or defense counsel. These usually result in the creation of a narrative report to respond to the questions.
Peer to Peer
A general term for a physician-to-physician conversation occurring as a component of utilization management or a medical file review.
Automated Approval Program
An automated solution that uses state mandated evidence based guidelines and our wealth of historical review data to provide your claims staff feedback on the need for utilization review, effectively eliminating unnecessary reviews.
There are many ways to say the same thing. The ultimate goal is to be able to rapidly provide the appropriate care to the injured employee in a cost effective way.