A utilization management physician assists the healthcare system with preventing overuse of medical resources and keeping healthcare costs down. They generally work with health insurers to review pre-authorization requests or review claims submitted by physicians. They may be responsible for communicating denial reasoning to physicians.
As insurers are playing an increasingly prominent role in the US healthcare system, physicians are being called to counsel regarding medical necessity, develop processes for cost-reduction, provide authorization for procedures, or review submitted claims submitted. Although some physicians have negative feelings toward insurers and the power that they hold over the healthcare industry (and sometimes what appears to be healthcare decision making), this proves that there is even more need for physicians to hold prominent roles in these organizations.
Physicians who work in disability review often review medical records of patients for whom claims have been filed, may perform independent medical exams, and write reports detailing their medical opinion as to whether the person qualifies for a payout regarding a medical disability. Physicians who are typically the most experienced with these types of claims are those in the fields of occupational medicine, PM&R, pain medicine, neurology, or orthopedics. Potential insurance employers are often looking for physicians within these specialties, as well.
There are many other areas of insurance review including review for approval of life insurance and pharmacy benefit reviews, among others, in which a physician in any field with clinical experience should be well qualified.
Disability Insurance Reviewer
|Pharmacy Benefit Reviewer|
▪ Review medical records and medical disability cases to determine qualification for payout
▪ Performing independent medical examinations for insurance reviewers
▪ Prevent medication over-prescribing and overuse
▪ Consider drug price, drug amount, and intended treatment
▪ Review pre-authorization requests
▪ Review medical claims to validate medical necessity
|Example Employer||▪ Disability insurer||▪ Pharmaceutical insurer||▪ Insurance company|
Job responsibilities in the field of insurance review and utilization management can include positions in disability case review, pharmacy benefit review, life insurance review, and utilization review.
Various job responsibilities may include:
- Reviewing pre-authorization requests to determine if procedures are necessary and help reduce health care resource overuse
- Reviewing claims submitted by physicians to determine medical necessity.
- Reviewing medical records and medical disability cases to determine qualification for payouts
- Discussing clinical practice guidelines and recommendations regarding testing with fellow physicians
- Writing reports on medical reviews detailing findings and medical opinion on state of health and whether medical disability is present
- Determining necessity of pharmaceutical drug benefit coverage.
- Performing independent medical examinations for insurance reviews
- Preventing medication overprescribing and overuse
- Considering drug price, drug amount, and intended treatment in pharmaceutical review
- Reviewing hospital inpatient records to validate medical necessity of hospitalization
Work Environment and Schedule
Mid-career physicians seeking a change of pace or those who need more career flexibility to devote time to family or other responsibilities may find that insurance review work fits their needs. The work schedule is generally flexible, with part-time or consultant work available with some organizations. Physicians can retain some clinical duties, if they would like, and they can often review cases remotely.
Depending on the specific role taken, many physicians have the freedom to use their diagnostic and reasoning skills to make decisions regarding claims, review of benefits, and pre-authorizations. One frustrating part of the job can be communication with other physicians who disagree with a utilization determination that you’ve made. They may be upset that a claim has been denied, disagree with your rationale, or feel that they are being put in a difficult situation regarding how to best manage their patient. Similarly, examining patients who may be trying to conceal a medical condition in order to receive payouts or qualify for life insurance occasional make the independent medication examinations difficult.
Required Skills and Training
To review medical records and provide expert medical opinion on the findings, insurance companies require physicians to be board certified and retain an active license. Although there are medical professionals that perform insurance claim review full-time, many companies prefer to find physicians that retain some clinical responsibilities. It lends more weight to their opinions if they are a practicing physician or have extensive experience in their field.
Required skills include:
- Clinical experience in managing a range of pathologies and populations
- Up-to-date knowledge of evidence-based medical guidelines and accepted standards
- Knowledge of Medicare, Medicaid, and other reimbursement programs
- Excellent communication skills both over the phone and in written format.
- Experience formulating and implementing policies and procedures
- Many companies prefer physician consultants who retain clinical duties versus full time reviewer employees
Residency, Licensure, and Training Requirements
- Board certification and an active license are typically required
- Some employers have a high preference for physicians certified in occupational medicine, pain medicine, neurology, psychiatry, or other specialties, depending on the range of coverage products they provide
Is This a Career for You?
Physicians who are looking for more lifestyle flexibility and have an interest in improving the healthcare system overall by reducing healthcare costs may enjoy a role in utilization management. Insurance review may allow physicians to practice part time, still examine patients for independent medical exams for insurers, or work remotely if they need more work flexibility. These roles may be great for physicians who are confident in clinical practice guidelines and what is appropriate care for the patient and cost effective for the system.
Physicians entering these roles need to be prepared to defend their decisions, express their medical opinions well in writing, and speak with both medical and insurance providers.
Depending on the role you obtain, the ability to use independent clinical judgement versus following clinical practice guidelines may vary greatly. Although the flexibility of this position may seem suited to those who want to be their own boss, physicians must remember that they are still employed or working through a contract with insurance companies and are subject to those organizations’ guidelines. These positions are regulated by insurance companies and could be subject to more stringent guidelines and regulations in the future, which could be a source of frustration for some physicians in the field.