Define: Concurrent Review

Concurrent review is a process used by insurance companies and healthcare providers to assess the medical necessity and appropriateness of ongoing treatment or services while a patient is still receiving care.

Concurrent reviews are typically conducted by qualified healthcare professionals, such as nurses or medical reviewers, who have expertise in the specific area of treatment being reviewed.

Concurrent review helps ensure that patients receive the most appropriate and cost-effective care by evaluating the ongoing need for treatment, monitoring progress, and identifying any potential issues or alternatives.

A concurrent review is often used by insurance companies to determine whether ongoing treatment or services meet the criteria for coverage under the patient’s insurance policy. If the review determines that the treatment is not medically necessary, insurance coverage may be denied.

Yes, if a patient disagrees with the outcome of a concurrent review, they have the right to appeal the decision. The appeals process typically involves submitting additional documentation or evidence to support the medical necessity of the treatment.

Yes, there are legal requirements that govern the process of concurrent review. These requirements may vary depending on the jurisdiction and the type of healthcare provider or insurance company involved.

Healthcare providers can ensure compliance with concurrent review requirements by staying informed about the applicable laws and regulations, maintaining accurate and detailed patient records, and following established protocols for conducting and documenting concurrent reviews.

Concurrent review decisions should be based solely on medical necessity and the appropriateness of care. It is illegal for insurance companies or healthcare providers to make decisions based on financial considerations or incentives.

If a patient believes their concurrent review was mishandled, they should first contact their insurance company or healthcare provider to discuss their concerns. If the issue is not resolved, they may consider filing a complaint with the appropriate regulatory agency or seeking legal advice.