Utilization review

Utilization review (UR) is a health insurance company's opportunity to review a request for medical treatment. The goal is to determine whether the plan will cover the treatment. The review is usually done as part of the approval process for a treatment request. The review can be done before the treatment is provided, retrospectively after the treatment is done, or concurrently while the treatment is being done.

History

The concept of utilization review has its roots in the 1970s. It was during this time that health care costs began to rise significantly. In response, insurance companies and government programs like Medicare and Medicaid began to look for ways to control costs. One method that was developed was the utilization review.

Process

The utilization review process begins when a medical provider makes a request for a treatment. The request is sent to the insurance company where it is reviewed by a medical director or a team of medical professionals. The review team will look at the proposed treatment and compare it to the patient's insurance policy to determine if the treatment is covered.

If the treatment is covered, the request is approved and the treatment can proceed. If the treatment is not covered, the request is denied. The patient and the medical provider have the right to appeal a denial.

Types of Utilization Review

There are three main types of utilization review: prospective, concurrent, and retrospective.

Prospective Review

A prospective review is done before a treatment is provided. The goal is to determine whether the proposed treatment is medically necessary and covered by the patient's insurance policy.

Concurrent Review

A concurrent review is done while a treatment is being provided. This type of review is often used for ongoing treatments like hospital stays or complex medical procedures.

Retrospective Review

A retrospective review is done after a treatment has been provided. The goal is to determine whether the treatment was medically necessary and to ensure that the treatment was provided in the most cost-effective manner.

Criticisms

Utilization review has been criticized for putting too much power in the hands of insurance companies. Critics argue that medical decisions should be made by doctors and patients, not insurance companies.

See also

• Health insurance
• Healthcare reform
• Managed care

Utilization review Resources
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