Why the Traditional UR Model No Longer Works: Part I
By Tiffany Ferguson, LMSW, CMAC, ACM, FCM
In many hospitals, utilization review (UR) still operates much as it did 20 years ago. Reviews often begin only after a patient has been admitted or a procedure has been completed. Nurses are assigned by unit, physician advisors are consulted primarily for status conversions or peer-to-peer reviews, and much of the work is tracked through spreadsheets, emails, and manual lists.
Although this model has served organizations for years, today’s technology environment has fundamentally changed the role and expectations of utilization management.
The phased removal of the Medicare Inpatient-Only (IPO) List, continued growth of Medicare Advantage (MA), and increasing payer scrutiny have exposed the limitations of a reactive UR model. Rather than asking whether a patient met criteria after admission, organizations now must identify the appropriate level of care earlier in the patient’s journey and actively support their physicians, who are documenting the clinical rationale for those decisions.
This shift requires UR to evolve, not just from a compliance standpoint, but also into an operational strategy that simultaneously supports patient progression, physician decision-making, and revenue integrity.
While medical necessity criteria remain an essential component of the review process, they should not be viewed as the endpoint of utilization management. As technology continues to advance to support increased scale and UR production, professionals should start considering how their position is going to shift – and reevaluate what requires a nurse to fill a supportive role for items such as sending clinicals and inputting payer responses.
For top-of-license performance, the role of the UR specialist will be moving to evaluate and support the information that may be part of the patient’s record, but was not captured in the patient’s provider documentation. This subtle but important shift transforms UR from an auditing function, checking the boxes for “met” and “unmet” reviews, into a collaborative clinical partner that works alongside providers, clinical documentation integrity (CDI), case management, and physician advisement to improve documentation, ensure the appropriate level of care, and prevent avoidable denials before claims are submitted.
Many organizations continue to rely on disconnected spreadsheets, email communication, and manual tracking processes that create unnecessary rework and limit visibility into the UR process. These fragmented workflows make it difficult to measure physician advisor involvement, identify authorization delays/denials, or provide meaningful operational feedback across clinical and revenue cycle teams.
Technology vendors, electronic medical record (EMR) workflows, and work queues allow organizations to automate referrals, monitor medical necessity milestones, and create transparent communication – and tell a data story across the continuum of the clinical and revenue cycle. Thus, the ideal UR specialist is not necessarily the seasoned nurse, but someone with effective communication and technology skills.
Healthcare has reached a pivotal moment wherein UR can no longer function solely as a retrospective review mechanism. By shifting interventions earlier, strengthening physician collaboration, and focusing on operational efficiency, rather than status correction, hospitals can improve compliance, reduce denials, and better support both patients and providers.