What is the Purpose of Utilization Review?

Utilization review, also termed utilization management, involves the review of care to determine medical necessity of specific treatments either before or after they are received, depending on the type of care received or the urgency of treatment. Understanding the purpose of utilization review can offer a patient insight into her medical care.

Purpose

• The purpose of the utilization review is to determine if the health insurance company should provide medical services. Utilization review examines medical files and treatment guidelines for a specific symptom or health condition.

Pre-Authorization

• Many insurance companies require pre-approval for health services, such as outpatient surgery, non-emergency hospitalization, and radiology services. The hospital coordinates with the prescribing physician office to determine whether the requested service is medically necessary for the patient.

Inpatient Stay

• If a patient is admitted to a hospital as an inpatient, the hospital will provide medical records to the insurance company to provide proof of medical necessity for care. The utilization review of an inpatient stay will require information regarding symptoms, diagnosis, and results from lab tests.

Retroactive Review

• In some cases, patients may require a retroactive review of medical services after treatment is received, especially if medical care is ongoing for cancer or another medical condition. The insurance company examines medical records to determine if the medical care was appropriate with the cost of care.