Utilization Review Definition

When health care organizations need to evaluate data about the services they provide to patients, an easy way to get information is to conduct a utilization review. Utilization reviews can provide health care administrators with various types of data about treatment services.

Definition

• Utilization review methods are used to evaluate the efficiency, appropriateness, necessity and efficacy of health care services that patients receive. It is conducted by auditing medical charts and related documentation about a patient's care.

Function

• Utilization review serves to provide a health care organization with information about how their medical services are being utilized by patients. Health care administrators use the data found in utilization reviews to make projections about things like funding and process improvement protocols.

Features

• Utilization review is most often performed by nursing or medical staff. Individuals with clinical backgrounds are preferred for these positions because they have formal training in medical service delivery.

Benefits

• By performing utilization reviews, health care administrators can maintain patient safety, ensure patients are receiving appropriate services, reduce medical adverse reactions, eliminate unnecessary treatment and deliver services more efficiently.

Medical Necessity

• According to the December 2000 issue of Journal of Health and Social Policy, some managed care systems, such as Medicaid, require utilization reviews to be performed to ensure medical necessity. Medical necessity relates to the appropriation of medical treatment, and utilization review can detect medical services that are not medically necessary.