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3 lawmakers support ‘utilization review’ of medical referrals

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AT least three lawmakers have expressed support for the plan of the administration to conduct a “utilization review” of medical referral patients in an effort to reduce unbudgeted costs.

The lawmakers are Rep. Janet U. Maratita, Rep. Joseph Leepan T. Guerrero, and Senate Vice President Jude U. Hofschneider.

Hofschneider and Maratita were among the lawmakers who met with the governor to discuss the need to reduce government spending, including medical referral costs.

The governor informed lawmakers that a utilization reviewer will look into the medical treatment and care provided to the patients.

Utilization review is part of the rules and regulations of the CNMI medical referral program, but Maratita said there is no utilization reviewer right now.

She added that this is why, in many cases, the government paid for diagnosis that is not in the approved medical referral trip.

According to the medical referral rules, “All medical bills incurred by a patient at the referral health care facility shall be subject to utilization review by the appropriate Medical Referral Services staff or contracted personnel. In those cases where a patient is referred to a referral health care facility in the State of Hawaii, it shall be the primary responsibility of the utilization review personnel employed by Medical Referral Services to review the medical treatment and care provided to the patient and to audit the medical bills prior to their payment by Medical Referral Services.”

Maratita said she supports “the idea of re-establishing utilization review.”

The administration is now working with a health insurance provider to assist in the activation of a utilization review for medical referral patients, she added.

Maratita believes that a utilization reviewer will help control medical referral costs.

Right now, she said, “there are cases in which a patient is diagnosed with a heart condition for example, but when the patient arrives on Guam for medical referral, he or she just takes it upon themselves to have other physical checkups and then, if something else is diagnosed, the cost will increase. And that is why we need a utilization reviewer now.”

Hofschneider said if a utilization review is a step in the right direction, then “I support it.”

Guerrero, who also supports a utilization review, said another way to “save” money is for the Commonwealth Health Center to bring in specialists.

Guerrero said CHC and other autonomous agencies such as the Commonwealth Utilities Corp. and the Commonwealth Ports Authority should allow the private sector to invest in their operations, which will reduce government costs, he added.

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