What does "utilization review" involve?

Utilization review is a critical process in healthcare that centers on evaluating the necessity and appropriateness of healthcare services provided to patients. This involves assessing whether the medical services, procedures, or treatments delivered meet established criteria for medical necessity, as well as their effectiveness and efficiency.

The primary goal of utilization review is to ensure that patients receive care that is medically appropriate while also managing costs. It typically includes reviewing patient records, treatment plans, and the rationale for specific medical interventions. This oversight helps to prevent unnecessary procedures and ensures that healthcare resources are used effectively.

Understanding the nature of utilization review can help clarify why it does not encompass aspects like claims processing, which focuses on payment rather than the appropriateness of care, or analyzing financial details of insurance policies, which is a separate function altogether. Similarly, evaluating provider eligibility is related to network management rather than the direct assessment of patient care services.