Autumn 2025 Issue

Documentation Dilemmas: Upon Further Review
By Michelle Wyatt, DNP, MSN, RN, CMS
For The Record
Vol. 37 No. 3 P. 8

What Is Concurrent Review?

Concurrent review is a utilization review (UR) process that occurs while a patient is actively receiving treatment, such as during a hospital stay. It evaluates the medical necessity and appropriateness of ongoing health care services to ensure the patient is receiving the right level of care, at the right time, in the right setting.

Considering its importance to utilization managers, concurrent review has received significantly less attention than prior authorization review. While prior authorization has made many headlines over the past year,1,2 concurrent review has not. Yet missteps in both processes leave hospitals in danger of not getting paid, which can result in higher costs being passed down to patients.

A closer look reveals the danger of overlooking concurrent reviews as hospitals and health systems scrutinize their UR practices.

Utilization Review
UR concerns the collection of information at the initial point of admission, and during and after treatment in a patient’s care, to evaluate medical necessity and the appropriateness of care related to desired outcomes.

UR consists of three phases:

1. Prior authorization review, sometimes known as pre- or prospective authorization review, occurs prior to the administration of treatment. These reviews ensure the requested care is medically appropriate.

2. Concurrent review. Besides monitoring ongoing health care services for admitted patients, concurrent review can involve care coordination across multidisciplinary teams, disease management, discharge planning, and transitions to other care facilities. This process helps prevent unnecessary or prolonged care, improve patient outcomes, and manage health care costs. Unlike prior authorization, which is obtained before treatment begins, concurrent authorization is needed during the treatment to ensure it remains medically necessary and covered.

3. Retrospective review occurs after treatment has been administered to evaluate the success of the provided care and determine whether the billed codes are correct. Additionally, through retrospective reviews, utilization management guidelines are regularly updated based on treatment efficacy. Future requests for these treatments are then more likely to be approved based on previous successes. This review process is especially important as new treatments and medications enter the market.

Concurrent and retrospective reviews take place behind the scenes, so that patients are likely unaware that these processes are occurring. While concurrent and retrospective reviews might not directly impact the cost to the patient, they impact payments received by the hospital for care provided to the patient.

Prior Authorization
Many headlines around prior authorization arose when the CMS prioritized fixing it. Last year, CMS established a January 2027 deadline by which impacted payers must implement a prior authorization application programming interface to facilitate electronic prior authorization requests and responses, with a focus on streamlining the process and improving interoperability.

The CMS “final rule” will require impacted payers to send prior authorization decisions within 72 hours for urgent requests, and seven calendar days for nonurgent requests, for medical items and services. Not only does prior authorization have an outsized fiscal impact on hospitals and health systems compared with concurrent review, Medicare only reviews and pays for claims submitted during the prior authorization review process.

Further, we are all patients and, therefore, more aware of prior authorization processes. For example, before a surgery is scheduled or a prescription is refilled, patients are typically made aware of when insurance has authorized it and can even be provided with a patient balance bill estimate ahead of time. Because concurrent authorization takes place behind the scenes, it simply hasn’t captured the same spotlight.

Behind the Scenes
There are several reasons why concurrent review processes demand attention as an integral reason for the financial crisis impacting the health care industry—
and patients.

1. Denials. Each denial is handled per the specific contract terms between each payer partner and the associated hospital. Concurrent denials, peer-to-peers, and formal appeal processes may all call for different processes per payer. Yet many directors of case management may be unaware of what comprises those contracts.

Medical necessity denials comprise a $2.5 billion problem for health care organizations each year.3 That’s around $5 million in denials per provider (on average each year) written off due to misalignment on how claims were handled, processed, and/or misinterpreted between stakeholders regarding what should be considered medically necessary treatment for the patient.

2. They present an opportunity for strategic focus by UR managers. Because concurrent review occurs in real-time, its benefits are less immediately visible compared with prior authorization or retrospective review. That presents the misguided view that it’s merely an administrative hurdle. On the contrary, concurrent review presents a strategic opportunity to optimize care delivery and coordination.

How expensive is this problem? Avoidable delays in care make up roughly 25% of an average length of stay (1.2 of 4.2 days), which equates to 10.8 million avoidable inpatient days. That’s 29,590 full hospital beds for an entire year. The average room costs $2,873 a day, so a total of $1.5 billion could be saved annually just by reducing avoidable days by 5%.

3. By continuously evaluating the medical necessity of ongoing treatments, concurrent review minimizes delays for patients as they are already receiving care, creating more seamless transitions of care. This ensures timely access to vital treatments while still allowing payers to manage costs responsibly. While it might not directly impact the immediate cost to the patient, it streamlines the process for providers, allowing them to focus on delivering quality care.4

How important are more seamless transitions of care? Some studies indicate up to one-fifth of patients experience an adverse event within two weeks of hospital discharge, many of which could have been mitigated or prevented. The reported cost of medical errors is wide-ranging, with some experts estimating $20 billion each year and others approximating health care costs of $35.7 to $45 billion annually for hospital-acquired infections alone.5

Conclusion
Concurrent review is a linchpin in the care continuum—undervalued not because it’s unimportant, but because its benefits are often behind the scenes. With rising financial pressures and increased focus on value-based care, investing in smarter, more integrated concurrent review processes is not just necessary, it’s urgent.

— Michelle Wyatt, DNP, MSN, RN, CMS, is the senior director of utilization review services at Xsolis and has over 20 years of experience in health care. She currently oversees the Xsolis clinical teams that lead customer implementation.

 

References
1. Henry TA. Prior authorization fixes earn majority support in Congress. American Medical Association website. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-fixes-earn-majority-support-congress. Published November 21, 2024.

2. Henry TA. 10 states have tackled prior authorization so far in 2024. American Medical Association website. https://www.ama-assn.org/practice-management/prior-authorization/10-states-have-tackled-prior-authorization-so-far-2024. Published August 19, 2024.

3. Bishop J, Manrique K, Fazzio M. Commercial medical necessity edits are your key to fewer denials. HealthCatalyst website. https://www.healthcatalyst.com/learn/insights/why-healthcare-claims-management-is-your-key-fewer-denials

4. Patel A. How AI can accelerate prior and concurrent authorization processes. Medical Economics website. https://www.medicaleconomics.com/view/how-ai-can-accelerate-prior-and-concurrent-authorization-processes. Published May 3, 2024.

5. Rodziewicz TL, Houseman B, Vaqar S, Hipskind JE. Medical error reduction and prevention. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2024.