This measure is important because it demonstrates that over time, there has been increased alignment between the Utilization Review Clinician level of authorization and the providers requested level of authorization.
Any provider may ask that the DVHA reconsider a decision. There are 2 levels of reconsideration reviews. The first level is the secondary review, where DVHA reconsiders an authorization decision based on the clinical documentation from the medical record and written documentation from the attending physician demonstrating why the provider believes the DVHA should have made a different decision. If a provider disagrees with DVHA’s secondary review decision, the provider may then request a doctor to doctor review, where the facility’s physician and/or Medical Director speaks with the DVHA designated physician for final review of the authorization decision.
In SFY16, our unit identified that there were significant discrepancies between the Utilization Review Clinician levels of authorization and provider requests. Interventions such as outreach and collaboration with providers as well as increased collaboration with AHS sister departments were implemented to address these discrepancies. These interventions contributed to a significant decline in reconsideration reviews over the past 5 years. Since 2018, secondary reviews have been less than 2% and doctor to doctor reviews have been less than 1% of total number of admissions. There was a slight increase in the number of reconsideration reviews from SFY19 to SFY20. This increase may be the result of personnel changes in the DVHA Utilization Review team as well as provider personnel changes.
Narrative last updated: 12/03/2020