What is concurrent review in health insurance?

What is concurrent review in health insurance?

• A. A method for underwriting risk during policy issue.
• B. The audit of medical bills for overcharges.
• C. Where the insurer monitors the length of a hospital stay.
• D. The process of reviewing a claim after payment.

Answer: (C)

Concurrent review is a utilization-management step that happens while the patient is still in the hospital. The insurer or a reviewer looks at the ongoing medical care and the length of the inpatient stay to determine whether that level of care is medically necessary and appropriate and to plan for discharge. It helps decide if the patient should remain hospitalized, transition to a lower level of care, or require additional services, with the aim of avoiding unnecessary days in the hospital and controlling costs. This is different from prospective review, which occurs before or at admission to authorize care, and retrospective review, which occurs after discharge and after payment to evaluate care and billing. The idea of monitoring the length of stay during the hospital stay best fits concurrent review.

Concurrent review is a utilization-management step that happens while the patient is still in the hospital. The insurer or a reviewer looks at the ongoing medical care and the length of the inpatient stay to determine whether that level of care is medically necessary and appropriate and to plan for discharge. It helps decide if the patient should remain hospitalized, transition to a lower level of care, or require additional services, with the aim of avoiding unnecessary days in the hospital and controlling costs. This is different from prospective review, which occurs before or at admission to authorize care, and retrospective review, which occurs after discharge and after payment to evaluate care and billing. The idea of monitoring the length of stay during the hospital stay best fits concurrent review.