Expanding into new services—like PHP, IOP, or ABA—can unlock major growth opportunities. But if your utilization review (UR) process isn’t aligned from day one, it can also trigger denials, compliance flags, and slowdowns in reimbursement. In this guide, we outline three common UR mistakes that cost small practices time and revenue—and how to prevent them with better planning or external support. Learn more about our utilization review services here.
1. Incomplete Documentation at Level of Care
One of the most common—and avoidable—causes of denials is failing to document medical necessity properly for the level of care billed. When launching a new program, it’s easy to miss payer-specific requirements for progress notes, assessments, or daily treatment plans.
Example: A small IOP launches quickly but uses generic templates that don’t meet regional Medicaid guidelines. Even though clients are attending, the claims are denied due to insufficient documentation.
Best Practice: Ensure UR protocols include documentation templates tailored to each payer and level of care. A partner like Capture RCM can help implement this before your first claim is submitted.
2. Misaligned Utilization Review and Billing Teams
When UR and billing functions operate in silos, information gaps emerge—especially during program rollout. Authorization timelines, session limits, or medical necessity updates may be missed, leading to delayed or rejected claims.
Key stat: According to the Healthcare Financial Management Association (HFMA), as much as 20–25% of denials stem from mismatched information between utilization review and billing functions.
Solution: Align your UR and billing workflows—or work with an integrated team that handles both. Capture RCM’s utilization review services are built to coordinate with billing, ensuring authorization, documentation, and reimbursement are always in sync.
3. Treating UR as Reactive Instead of Strategic
In growing practices, utilization review (UR) is often viewed as an administrative checkbox. But strategic utilization review improves not just compliance, but revenue predictability and payer trust.
When launching a new program, proactive UR can help:
- Pre-identify authorization bottlenecks
- Validate that care plans meet medical necessity criteria
- Set internal review timelines before payers request them
Pro Tip: Build UR into your program launch checklist—not just post-admission. Practices that treat UR as an intake-to-discharge tool reduce authorization denials by up to 30%.
Consider the Build vs. Buy Decision
Building an internal UR system requires experienced reviewers, payer policy knowledge, and dedicated staff time. For many small practices, outsourcing utilization review to a behavioral health specialist offers better ROI, especially during expansion.
Outsourced UR services help you:
- Prevent denials before they happen
- Stay compliant with evolving payer rules
- Free up clinical teams to focus on care delivery
Explore our billing services and utilization review support to see how we help small programs scale smoothly.
📞 Ready to reduce denials and set your new program up for success?
Call (380) 383-6822 or visit our billing services page to learn how Capture RCM helps small practices launch new programs with confidence—through expert utilization review, clean documentation, and payer-ready processes.
