A Medical Utilization Review System for Ambulatory Care Based on Automated Claims Data

Abstract

This article describes the use of an automated claims data base in reviewing the quality and medical necessity of ambulatory care provided to beneficiaries. The primary advantage to this approach is economy, since the data elements used in the review process are routinely collected as part of the claims payment process. This paper addresses issues relevant to the selection of physicians for review, strategies for improving the review process, and results of reviews conducted to date.Over the course of the last four years, the United Mine Workers of America Health and Retirement Funds has developed and implemented a medical utilization review (UR) system based on the review of claims data. The system has two primary purposes: (1) to improve the quality of medical care provided to Funds' beneficiaries, and (2) to reduce Funds' expenditures for unnecessary medical services. The approach we have selected is unique in that it relies primarily on a computerized claims data base in order to select physicians for review and in order to reach a preliminary assessment of a physician's pattern of care.To date, we have had the opportunity to examine statistically the practices of more than 600 primary care physicians who account for yearly billings in excess of $33 million. In addition, we have conducted peer review on more than sixty physicians and have intervened in nearly forty practices. Based on these experiences, we have gained valuable insights into effective strategies for using computerized claims data in the review of ambulatory care. In conducting such reviews, the Funds has one important advantage. The vast majority of Funds beneficiaries are elderly.