What is a Utilization Review?

Mary McMahon
Mary McMahon

A utilization review is a procedure to evaluate how services are being used and delivered, to confirm that they are being utilized in a way which is efficient and cost effective. Utilization reviews are most commonly seen in the context of health care, where they may be conducted by insurance companies, hospitals, and other institutions involved in the delivery of health care. If the results of a utilization review suggest that requests for services should be denied, it is usually possible to appeal.

Utilization reviews are most commonly seen in the health care field.
Utilization reviews are most commonly seen in the health care field.

Since health care is the field in which utilization reviews are most commonly used, this article will focus on the use of such reviews in the health care field. A utilization can occur before treatment is provided, during treatment, or after. Certain types of treatment may trigger automatic reviews, while others may be reviewed due to the specifics of the case, the patient, or the facility.

Insurance companies use utilization reviews to determine whether they will cover a procedure or if the policyholder must pay out of pocket.
Insurance companies use utilization reviews to determine whether they will cover a procedure or if the policyholder must pay out of pocket.

In a utilization review, a person or panel of people sits down to go over the specifics of the case and the recommended treatment. For example, if a patient has cancer, the board will discuss the type of cancer, the staging, the age of the patient, the prognosis, and so forth. The board will also discuss the treatment recommended by a doctor. They must decide in the utilization review whether or not the treatment fits in with established treatment guidelines, and they must consider whether it is necessary or appropriate.

Insurance companies use utilization reviews to determine whether or not something is covered. Hospitals use them to determine whether or not they should offer a service, typically performing reviews when a case could be expensive or time consuming. So, for example, if a woman has breast cancer and needs a mastectomy, the utilization review panel will likely sign off on the treatment. If, on the other hand, a woman wants a prophylactic mastectomy because she is concerned about developing breast cancer later in life, the utilization review may determine that this does not meet existing treatment guidelines, and is therefore not appropriate.

Ultimately, a utilization review or UR does not determine whether or not a patient is allowed to receive treatment, but it does determine whether that treatment is covered by insurance or whether or not it will be allowed at a particular hospital, which can amount to the same thing. Many patients cannot afford treatments which are deemed nonessential, and may opt to appeal the results of the utilization review if they feel that a procedure or treatment really should be covered.

The prognosis of a cancer patient may be discussed during a utilization review.
The prognosis of a cancer patient may be discussed during a utilization review.
Mary McMahon
Mary McMahon

Ever since she began contributing to the site several years ago, Mary has embraced the exciting challenge of being a wiseGEEK researcher and writer. Mary has a liberal arts degree from Goddard College and spends her free time reading, cooking, and exploring the great outdoors.

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Discussion Comments

anon74530

Are there any free automated guidelines in utilization review for workers compensation?

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