Performing UR and Asking Clarifying Questions

Asking the right question at the right time facilitates the UR process and the accuracy of the case

Performing utilization review (UR) is similar to performing an investigation. First, there is fact-finding; then comes the review of the evidence, in this case, supporting documents; and finally, decision-making. These steps may need to be repeated until a decision can be reached with good confidence. Since the last two steps are self-explanatory, this section focuses on the fact-finding component of the UR process.

Fact-finding may include the following aspects:

Looking at the “who, what, when, and why” of the request
Asking clarifying questions
Compiling submitted documents
Gathering additional pertinent information

The fact-finding step can be quite simple. When adequate supporting documents are submitted simultaneously with the authorization request and the "who, what, when and why" are clear, there is no need to ask for additional information. In these cases, UR clinicians review the request and submitted documents, then determine if the information available meets established clinical criteria, guidelines, or protocols to make a decision.

For other cases, asking for pertinent supporting documents is essential to decision-making. UR clinicians and/or their assistant(s) may need to request documents to support the medical necessity of the requested service(s) or for service(s) currently underway, such as a hospitalization. Supporting documents can come from various sources, including but not limited to: primary care provider and specialist notes, laboratory and diagnostic test results, procedure and surgery reports, therapy notes, etc.

Fact-finding also includes asking clarifying questions about the request itself. Knowing some general information before starting a case review or during a case review can lessen the time* spent on the review process and facilitate the right decision.

To avoid unnecessary case reviews and to expedite the UR process, some questions should be asked before starting a case review, while other questions should be asked during the case review process. Below are examples of clarifying questions that UR clinicians should, as appropriate, routinely ask about the circumstances of the case. These questions are not typically addressed in clinical or medical criteria/guidelines (e.g. Medi-Cal criteria, CMS National or Local Coverage Determinations, MCG, InterQual®, etc.) that address the medical need for services.

*Please review the next drop-down UM section, Timelines for Decisions to learn about decision-making timelines.

Insight

Documents can be in the form of a paper copy, such as via fax or mail or in an electronic format. Paper documents are typically scanned into the organization's database.

It is better to have written documents than to just have verbal conversations with providers since all supporting documents used to make adverse decisions must be kept in case of an appeal, audit, or other regulatory/agency review. If the UR clinician can only obtain verbal information, then clear and concise documentation in the case notes is essential.

UR Questions to Ask

PLEASE NOTE: Sophisticated IT systems may have automated algorithms that address these questions.

The below Q & As are most applicable to UR activities performed in managed care organizations but may be noteworthy to other entities that perform UR activities.

Who is the primary health plan?

Reason to Know: If the health plan you are employed by is secondary payor, then reviewing the service request may be inappropriate since the primary health plan is the entity that is responsible for service payment. However, if the primary health plan has already denied or made an adverse decision about the requested service, then the review may be appropriate. Given the above, the UR clinician should be aware of applicable Coordination of Benefits (COB) rules. Click on the titles below.

National Association of Insurance Commissioners- COB Model Regulations

California Code of Regulations (CCR), Title 10, § 2232.56. Effect on Benefits, Standard Provision for Coordination of Benefits

CCR, Title 28 Managed Health Care § 1300.67.13. Coordination of Benefits

Is the service covered by the health plan?

Reason to Know: If the service is not covered by the health plan, then the service can be denied for “not a covered benefit”. However, this is when the use of critical thinking skills in the decision-making process is essential.

Example: If a requested splint is not covered because the procedure code (CPT code) is not covered by the health plan, that does not mean a splint is not needed. A splint with a different CPT code may work; thus, the alternative splint should be offered.

Example: If a continuous glucose monitor (CGM) is not covered by the health plan, that does not mean that a CGM should not be authorized. For example, an exception could be made because the patient’s history of elevated Hemoglobin A1c and, multiple ER visits and hospitalizations for diabetic-related conditions. Consideration should be given to the cost of a CGM vs continuous ED visits and hospitalizations.

Is an out-of-network (aka: nonparticipating, noncontracting) provider being requested?

Reason to Know: If the requesting provider is asking for a service to be done by an out-of-network provider, the UR clinician needs to determine if the requested service can be provided by an in-network provider. If the service can be provided by an in-network provider, the service should be redirected to such provider. Thus, the requested service should be "modified" rather than "denied" since the service is allowed but with an in-network provider.

How long has the member received the service?

Reason to Know: If your organization does not have a number or dollar limit on a specific service, assessing the duration that a member has been receiving the requested service impacts the need for continuing care/services. While guidelines, criteria, or protocols exists, they may not answer pertinent questions related to the case.

Example: If a member had a stroke one year ago and has received home health physical therapy (PT), 3 times a week for the past 6 months, additional PT may not be warranted. The length of home PT may be excessive. The UR clinician needs to question the reason for continued therapy: 1) Is there a reasonable goal? 2) Is significant gain in function anticipated with additional PT? 3) If continued PT is necessary, can it be done at an outpatient clinic? 4) Can the member transition to a home exercise program? In general, home PT services has a limited duration; and generally, no more than 2-3 months. Moreover, the intent of PT is not to regain previous level of function but to help gain maximum functional level. Functional gains may have plateaued if no significant improvements are anticipated. Thus, transitioning to a home exercise program is the most appropriate level of service, rather than continued home PT.

Has this service been approved in the past?

Reason to Know: One aspect of the UR process is to avoid duplication of services. UR clinicians need to determine it the requested service or similar service has been performed in the past; why it was approved; when the service was rendered and its outcome; and, whether the service is needed again under the current conditions. Service duplication incurs unnecessary expenses and may cause unnecessary concerns and stress to the member.

Example: Two providers are involved in the care of the same patient. During visits (two weeks apart) with these providers, the patient was prescribed two different splints. Both providers were unaware that the other had ordered a splint, thus, the second splint is a duplication and should not be approved.

For Commercial Plans: Is the request for dialysis or kidney transplant for a member with ESRD/CKD?

Reason to Know: If a member is starting or currently receiving dialysis treatments for end-stage/chronic kidney disease, s/he may be eligible for Medicare. Thirty-three (33) months, which consists of 3 months waiting period and 30 months coordination period, from the date of Medicare benefit eligibility, the commercial plan will typically become the secondary rather than primary payor. Medicare may also be the primary for a kidney transplant and for a limited time thereafter. In either case, reviewing the request for dialysis treatments and/or transplant may be unnecessary since the commercial plan is no longer primary.

To learn more, read, Medicare Coverage of Kidney Dialysis & Kidney Transplant Services or go to: https://www.medicare.gov/Pubs/pdf/10128-medicare-coverage-esrd.pdf

For Medicare Advantage Plans: How long has the member had the DME, oxygen equipment, etc.?

Reason to Know: Medicare has capped rental limits for DME, oxygen equipment, orthotics, and prosthetic devices that are usually rented. Once a capped limit is reached, it may be unnecessary to perform UR for these cases since monthly rental fees are no longer allowed.

For rental DME, orthotics, & prosthetic devices, the capped rental is 13 months

For rental oxygen equipment, the capped rental is 36 months

After 13 or 36 continuous months of rental, the item belongs to the member. Please note that these items have a reasonable useful lifetime (RUL), which is typically 5 years. After 5 years, a new DME, oxygen equipment, etc. may be issued and the monthly rental starts again until the capped rental limit is reached.

To learn more about DME and oxygen equipment capped rentals and reasonable useful lifetime, go to Medicare Resources on this website.