Concurrent Review

Definition

Concurrent review is a type of utilization review conducted by an insurance payer during an active inpatient hospital stay. The payer evaluates whether the patient continues to meet medical necessity criteria for inpatient hospitalization and whether the planned length of stay is appropriate.

Why It Matters

Concurrent reviews determine how many hospital days are approved for payment. A denied concurrent review can result in unpaid inpatient days and significant revenue loss. Preparing thoroughly for concurrent reviews ensures approval for medically necessary stays. Poor documentation leads to denial and billing disputes.

How It Works

During an inpatient admission, the hospital notifies the patient's insurance payer. The payer contacts the hospital's utilization review team or case management to discuss the patient's clinical status, reason for admission, and expected length of stay. Payer reviewers (typically nurses or care managers) ask clinical questions to verify medical necessity. They review whether the patient's condition requires continued inpatient care or could be managed in a lower level of care. Based on their assessment, the payer approves a certain number of inpatient days. If the clinical picture changes and the patient no longer meets inpatient criteria, the payer may deny continued coverage. The hospital must notify the patient when inpatient coverage is denied. Utilization review processes vary by payer and plan type.

Related Terms

• Utilization Review
• Prior Authorization
• Medical Necessity