Utilization review ensures medical care is used correctly and efficiently. Nurses often perform utilization reviews and coordinate with health plans. You can appeal a decision if your health plan ...

Concurrent review is a utilization review process that occurs while a patient is actively receiving treatment, such as during a hospital stay. It evaluates the medical necessity and appropriateness of ...

California is among a handful of states that seeks to regulate the use of artificial intelligence (“AI”) in connection with utilization review in the managed care space. SB 1120, sponsored by the ...

Health systems and health insurance plans spend enormous sums of money battling over how to be paid fairly — and these battles have only intensified with the growth of Medicare Advantage plans, which ...

Humana will use healthcare technology firm XSOLIS’ predictive analytics platform to streamline parts of the utilization review process with providers. The payer will adopt the company’s various ...

On January 25, 2022, the U.S. Court of Appeals for the Second Circuit affirmed a lower court ruling that the Secretary of HHS violated the due process rights of Medicare beneficiaries by failing to ...

I need to do a drug utilization evaluation (DUE) for a new product to be added to our formulary. What resources are available to develop a DUE? The formulary system encompasses facets of medication ...

(Philadelphia, PA) – After examining data from six state Medicaid programs, researchers from the University of Pennsylvania School of Medicine have concluded that drug utilization review programs do ...

Cone Health is a North Carolina-based nonprofit health system serving patients across 150 locations, including five hospitals and more than 120 physician practices. It had a peer review paper-based ...

On April 3, the Pennsylvania Insurance Department issued a news release touting the relief provided by a new external review ...