Utilization review, also known as utilization management (UM), is a process used by health insurance companies and other payers to manage the cost of healthcare benefits by assessing the appropriateness of care prior to its provision. The goal of UM is to ensure that medical care is effective, efficient, and in line with evidence-based standards of care. UM techniques include prior authorization, concurrent review, and retrospective review.
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Prior authorization: This technique requires healthcare providers to obtain approval from the insurance company before providing certain medical services or treatments. The insurance company reviews the request and determines whether the service or treatment is medically necessary and appropriate.
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Concurrent review: This technique involves reviewing medical services or treatments while they are being provided to ensure that they are medically necessary and appropriate. The focus of concurrent UM is on reducing denials and placing the patient at a medically appropriate point of care.
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Retrospective review: This technique involves reviewing medical services or treatments after they have been provided to ensure that they were medically necessary and appropriate. Retrospective review can be used to monitor the accuracy of information provided during prior review and identify problem areas.
UM is typically performed by utilization review nurses or other healthcare professionals who have expertise in the relevant medical specialty. UM can help control healthcare costs and reduce inappropriate services without undermining patient access to needed care. However, it is important to note that UM can also be a source of ethical conflicts for healthcare providers.
