Utilization review (UR) teams play a critical role in ensuring the right care at the right level, protecting both patient outcomes and hospital reimbursement. Yet across the healthcare industry, many UR programs are weighed down by outdated workflows that consume valuable time without improving quality.
These habits often stem from legacy training, variable expectations, or a belief that more words mean more chances of authorization approval. In reality, overly detailed narratives slow the UR process, create unnecessary burden for reviewers, and do little-to-nothing to influence payer decisions.
For years, reviewers have been taught to write long, narrative summaries, reiterating physician notes and retelling the patient’s history and hospital course. The precise and thorough crafting of this summary is in addition to, and many times separate from, the application of medical necessity screening tools and level-of-care decisions.
Some reviewers feel obligated to prove they were thorough in their chart review by documenting even minute or irrelevant observations (and many UR leaders require it). Some reviewers are under the false impression that UR summaries are relied on to confirm coding or billing details. Another prevalent false belief is that payer reviewers often use hospital UR summaries to make their authorization approval decisions, and thus skimpy summaries lead directly to denials.
The real truth is that these long narrative summaries rarely add value. They aren’t read by payers, they are unnecessary to complete an effective and compliant utilization review, and they do not prevent denials. What these comprehensive summaries really do is steal precious time, hampering productivity by needlessly diverting the attention of high-value clinical resources.
The Hidden Cost of Extensive UR Narrative Summaries
Every unnecessary line written (or copied and pasted) in a UR narrative summary is time lost from the next review. When reviewers spend 10-15 minutes, or even longer, duplicating, rewording, or reformatting provider statements and clinical data points and details directly from the patient’s medical record, productivity is not being maximized.
This inefficiency can compound frighteningly quickly with staffing losses or census bumps, potentially leading to backlogs of unreviewed cases, and ultimately risking timely reimbursement. Burdensome narrative requirements can also increase reviewer fatigue.
UR is a decision-heavy field that requires consistent clinical judgement, interpretation of medical necessity criteria, and ongoing prioritization. When reviewers invest mental energy into composing narrative summaries, it steals returns on:
- Making accurate status decisions
- Collaborating with care teams
- Escalating complex or borderline cases
This impact can also extend to quality management. By nature, extensive, free-text notes invite inconsistency and inefficiency in quality assurance evaluations. Focusing on auditing anything beyond accurate application of guidelines (and potentially a few electronic health record (EHR), facility, or payer-specific administrative steps) gums up feedback loops, limiting the bandwidth available to:
- Audit more cases
- Identify trends in medical necessity decisions
- Coach teams and individuals on findings and opportunities
Across acute care organizations, the cumulative cost of this major yet very common inefficiency is significant: lower productivity, potential burnout, and inconsistent quality assurance. UR programs struggling to hit first-touch or medical necessity denial targets, as well as high-functioning UR programs, could benefit from an honest assessment of current UR workflow requirements and meaningful process updates.
Reframing the Purpose of the UR Process
To solve this problem, UR leaders must ensure they understand the true purpose of the utilization review, particularly in today’s complex payer ecosystem. The UR process is not the time to tell the patient’s story: it is a medical necessity and status decision (or escalation) and the record of that decision or escalation.
At its core, a compliant and efficient utilization review should demonstrate only three things:
- The reviewer applied appropriate and accurate medical necessity criteria, such as MCG, InterQual, and/or CMS guidelines.
- The objective findings support those criteria.
- An admission status determination or update was made or escalated.
When teams realign around this true purpose, UR workflows:
- Become more efficient
- Remain compliant
- Are easier to audit
The result is a faster, more consistent process that protects both productivity and quality.
Contact us to learn more about optimizing UR documentation and workflows, and watch for the next article in our utilization management series about how to implement an effective documentation framework.
