Comprehensive Utilization Review Services
Synergy Bill Pro’s utilization review (UR) program serves a vital role in healthcare delivery. Our team of experienced professionals provides customized services to ensure every patient receives the highest quality care to support the best outcome, curbing unnecessary expenditures and ensuring compliance with health plan rules and state and industry guidelines.
As an independent leader in healthcare quality, our utilization review process follows evidence-based protocols to ensure patients receive timely and appropriate care at every stage of their treatment.
Utilization Reviews Tailored to You
Synergy Bill Pro’s utilization review services support effective and efficient healthcare services in any setting. We’ll review medical records to ensure that care is medically necessary and delivered in accordance with plan benefits, in the right place, and at the right time.
The process occurs in several distinct stages before, during, and after care; we provide:
- Prospective reviews, also known as prior authorizations, before treatment to reduce duplicate or unnecessary services and claim denials while ensuring patients receive the most appropriate care.
- Concurrent reviews while the patient is undergoing treatment. This process ensures that the patient receives the correct care; if necessary, the UR specialist will recommend changes or improvements to secure a better outcome.
- Post reviews to ensure the patient received the best care possible and evaluate aftercare plans and case management protocols. These reviews help establish guidelines and processes for future patients.
Our services for healthcare payers, state programs, and self-insured employers help slash medical and indemnity costs while improving patient care. We find evidence-based solutions that minimize restrictions and resource usage to meet individual goals and care needs.
Choose Synergy Bill Pro for Utilization Management
The utilization review process is more than benefits verification. It allows healthcare payers and providers to coordinate care better and avoid unnecessary costs.
Our approach tailors utilization reviews to individual state and oversight agency requirements, payer criteria, and provider standards to ensure gold-standard assessments and excellence on every critical healthcare benchmark. Get in touch today to learn more about our URAC-certified services.
FAQS About Utilization Review
What is a utilization review?
A utilization review is a defined process by which claims administrators and healthcare payers determine whether healthcare treatment is medically necessary and whether the provider’s care plan is a cost-effective way to achieve the best outcome.
Which healthcare entities perform utilization reviews?
Insurance companies are most likely to have utilization review programs, but hospitals, home care agencies, and other providers also use the process. CMS rules require hospitals to have an effective UR process in place to participate in Medicare and Medicaid programs.
Who conducts utilization reviews?
Certified UR review specialists perform the individual case reviews. These professionals are typically registered nurses and healthcare providers with clinical experience and a background in case management.
What are the steps of a utilization review?
Doctors send a request for authorization to the payer, which then goes to UR. A UR specialist approves, denies, or modifies the request per evidence-based practices and sends the decision back to the provider.
