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🏥 '''Concurrent review''' is a [[Definition:Utilization management | utilization management]] process used in [[Definition:Health insurance | health insurance]] and [[Definition:Workers' compensation insurance | workers' compensation]] in which a clinical reviewer evaluates the medical necessity and appropriateness of care while treatment is actively underway. Rather than waiting until after services are rendered — as in [[Definition:Retrospective review | retrospective review]] — concurrent review allows the [[Definition:Insurance carrier | insurer]] or its [[Definition:Third-party administrator (TPA) | third-party administrator]] to make real-time decisions about continued authorization, discharge planning, and transitions between levels of care. This contemporaneous oversight is central to managing [[Definition:Medical loss ratio (MLR) | medical costs]] without compromising patient outcomes.

⚙️ Typically, a registered nurse or physician employed by the carrier or a specialized [[Definition:Managed care organization (MCO) | managed care organization]] monitors an admitted patient's progress against evidence-based clinical criteria — often benchmarks developed by organizations such as InterQual or Milliman. If the reviewer determines that continued inpatient stay is no longer medically necessary, the insurer may issue a denial of further inpatient [[Definition:Authorization | authorization]], prompting a step-down to outpatient or home-based care. The process involves close coordination with the treating physician and hospital case managers, and it must comply with state and federal regulations governing [[Definition:Adverse benefit determination | adverse benefit determinations]] and [[Definition:Appeal | appeal]] rights. In workers' compensation, concurrent review also encompasses monitoring return-to-work readiness and ensuring that treatment stays within [[Definition:Treatment guideline | treatment guidelines]] specific to the injury.

📊 Effective concurrent review directly impacts an insurer's [[Definition:Claims cost | claims cost]] trajectory and, by extension, its [[Definition:Combined ratio | combined ratio]]. Studies consistently show that timely intervention — redirecting patients to appropriate care settings before unnecessary costs accrue — yields better financial results than retrospective claim denials, which are harder to enforce and more likely to generate [[Definition:Grievance | grievances]] and regulatory complaints. For health insurers and self-funded employer plans alike, investing in skilled clinical reviewers and integrated technology platforms for concurrent review is one of the most reliable levers for controlling [[Definition:Loss ratio (L/R) | loss ratios]] while maintaining quality of care and member satisfaction.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Utilization management]]
* [[Definition:Prior authorization]]
* [[Definition:Retrospective review]]
* [[Definition:Medical loss ratio (MLR)]]
* [[Definition:Case management]]
* [[Definition:Third-party administrator (TPA)]]
{{Div col end}}

Definition:Concurrent review - Revision history

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