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Delegates approve protocol for third-party telephone review.

|August 1, 1989

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Physicians face increasing administrative burdens from telephone utilization reviews by third-party payers. The Texas Medical Association developed guidelines to help physicians navigate these reviews effectively.

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.

Related Experiment Videos

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.