What is the simultaneous review? – Medcity News

A simultaneous review is a process of testing for use that occurs while a patient actively receives treatment, as during a hospital stay. It assesses the medical need and the relevance of the current health services to ensure that the patient receives the right level of care, at the right time, in the right framework.

Given its importance for user managers, a simultaneous review has received much less attention than the prior examination of the authorization. Although the prior authorization has made many titles in the past year, a simultaneous review did not do so. However, the missteps in both processes leave hospitals in danger of not being paid, which can result in increased costs to patients.

A more in -depth examination reveals the danger of neglecting simultaneous journals while hospitals and health systems examine their user -use practices.

User review: an overview

The revision of use (UR) concerns the collection of information at the first point of admission and during and after processing under the care of a patient, to assess the medical need and the relevance of care linked to the desired results.

UR consists of three phases:

1. Prior authorization examinationSometimes known as the pre -prospective authorization examination, occurs before the administration of treatment. These examinations ensure that the requested care is medically appropriate.
2. Simultaneous review. In addition to monitoring the current health services for admitted patients, a simultaneous journal may involve coordination of care between multidisciplinary teams, disease management, holiday planning and transitions to other healthcare establishments. This process helps prevent unnecessary or prolonged care, improve patient results and manage health care costs. Unlike prior authorization, which is obtained before the start of treatment, simultaneous authorization is necessary during treatment to ensure that it remains medically necessary and covered.
3. Retrospective review Performs after the administration of treatment to assess the success of the care provided and determine whether the codes invoiced are correct. In addition, thanks to retrospective journals, use management directives are regularly updated according to the efficiency of treatment. Future requests for these treatments are then more likely to be approved according to previous successes. This examination process is particularly important because new treatments and drugs enter the market.

Simultaneous and retrospective criticisms take place behind the scenes, so patients probably do not know that these processes occur. Although simultaneous and retrospective journals may not have a direct impact on the cost of the patient, they have an impact on the payments received by the hospital for the care provided to a patient.

Why did the prior authorization take the spotlight?

Many titles around the prior authorization have occurred when the centers for Medicare and Medicaid Services (CMS) have prioritized the repair. Last year, CMS established a deadline of January 2027 by which the impacted payers must implement a prior authorization API to facilitate previous requests and electronic authorization responses, emphasizing the rationalization of the process and improving interoperability.

The “final rule” of the CMS will force the payers impacted to send previous authorization decisions within 72 hours for urgent requests and seven calendar days for non -urgent requests, for medical items and services. Not only does prior authorization have a disproportionate budgetary impact on hospitals and health systems compared to a simultaneous review, in Medicare only Examine and pay the complaints submitted during the process of examining the previous authorization.

In addition, we are all patients and, therefore, more aware of the previous authorization processes. For example, before a surgical intervention is provided or a prescription is completed, patients are generally informed as long as the insurance authorized it and can even be provided with an estimate of the balance in advance. Because simultaneous authorization takes place behind the scenes, it simply did not capture the same spotlights.

Why the simultaneous examination is undervalued, but must be improved now

There are several reasons why the simultaneous examination processes require attention as an integral reason for the financial crisis having an impact on the health care industry – and patients.

1. Refusal. Each refusal is managed according to the specific contract conditions between each paying partner and the associated hospital. Simultaneous refusals, peers-to-peers and formal call processes can all ask for different processes by payer. However, many cases of cases management may not be aware of what includes these contracts.

   Refusals of medical necessity include a problem of $ 2.5 billion for health care organizations each year. This represents approximately $ 5 million refusals per supplier (on average each year) struck off due to a dishealthy about how complaints have been processed, processed and / or misinterpreted between stakeholders concerning what should be considered a medically necessary treatment for the patient.

2. They have an opportunity for a strategic orientation of your managers. Since the simultaneous examination occurs in real time, its advantages are less immediately visible in relation to the prior authorization or the retrospective examination. This presents the erroneous opinion that it is simply an administrative obstacle. On the contrary, a simultaneous journal presents a strategic opportunity to optimize the service and coordination of care.

   What is the size of this problem? Avoidable delays in care represent approximately 25% of an average stay (1.2 of 4.2 days), which is equivalent to 10.8 million days of avoidable hospitalization. It is 29,590 beds at the full hospital for an entire year. The average room costs $ 2,873 per day, so a total of $ 1.5 billion could be saved each year simply by reducing the avoidable days by 5%.

3. By continuously assessing the medical need for current treatments, a simultaneous review minimizes delays for patients because they already receive care, creating more transparent care transitions. This guarantees timely access to vital treatments while allowing payers to manage costs in a responsible manner. Although it may not have a direct impact on the immediate cost for the patient, it rations the process for suppliers, which allows them to focus on quality care provision.

   What is the importance of more transparent care transitions? Certain studies indicate that up to a fifth of patients undergo an adverse event within two weeks of leaving the hospital, many of which could have been attenuated or warned. The reported cost of medical errors is variable, some experts estimating $ 20 billion each year and others approaching health costs from $ 35.7 to $ 45 billion per year for hospital infections.

Conclusion

The simultaneous review is a lamp pin in the care continuum – undervalued not because it is unimportant, but because its advantages are often behind the scenes. With the increase in financial pressures and the increased accent on value -based care, investing in smarter and more integrated simultaneous examination processes is not only necessary, it is urgent.

Photo: Eugene Mymrin, Getty Images

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