Home > Utilization Review Utilization Review Program (UR) Delphi’s Utilization Review Program (UR) on the surface appears much like other utilization review companies. However, there are substantial differences in our operation and our results. For example, utilization systems doing precertification look pretty much the same, they all use similar criteria, they have nurses looking into admissions and discharges, and they all document the reasons for medical necessity. Delphi performs all of those functions as well, but goes substantially further. While other UR companies stop after medical necessity is determined, this is where Delphi’s real work begins. We begin working with the patient as to whom, how when and where the medical services are to be rendered. We review with the patient the highest quality physicians they may choose from, the best facilities to go to, and continue to work with them throughout the episode of care to make sure the patient is getting what they need—and that the medical care is moving forward in a logical and productive manner. Once the episode of care is concluded, we may include them in our tracking system, following up with them periodically to make sure another episode of care does not occur, i.e. making sure they are taking their medication and following physician’s instructions. The most important difference Delphi makes is that we talk with the patients, as well as physicians about their medical care. Our UR nurses are armed with both quality and efficiency data on each physician and medical facility. That information allows the nurse to offer the patient the best medical providers and facilities within the area. Secondly, upon precertification our UR nurses enter into the claims system the exact services to be rendered under the precertification and many times pre-price the expected claims, so that the claims person handling the claim will pay only for the services ordered (other claims systems pay on the basis of a blanket precertification approval and will often pay for services not ordered). |
