Delegates approve protocol for third-party telephone review.

Area of Science:

• Healthcare Administration
• Medical Practice Management
• Physician Advocacy

Background:

• Private third-party payers and self-insured entities utilize telephone utilization review for hospital admissions.
• These reviews, often conducted by external firms, involve contacting physicians' offices for pre-certification and concurrent review.
• Current practices exhibit significant variability in procedures, criteria, and reviewer qualifications.

Purpose of the Study:

• To investigate the impact of telephone utilization review on physicians.
• To address concerns regarding the lack of regulation and control over review firms.
• To provide physicians with a standardized protocol for responding to these reviews.

Main Methods:

• The Texas Medical Association Physician-Patient Advocacy Committee conducted an extensive study.
• Analysis of physician and office staff experiences with telephone utilization review.
• Development of a recommended protocol based on physician feedback and concerns.

Main Results:

• Physicians and their staff are dedicating more time to managing telephone utilization reviews.
• Review firms operate without external regulatory oversight.
• Significant variations exist in the operational standards of review firms.

Conclusions:

• The Texas Medical Association has established a protocol to guide physicians in responding to private third-party telephone reviews.
• The protocol addresses critical areas including confidentiality, documentation, patient advocacy, appeals, and billing.
• This initiative aims to standardize and improve the physician's interaction with utilization review processes.