Utilization Review (UR) or
Utilization Management (UM)
 | Systematic means for reviewing and controlling patients’ use of health
services and providers’ use of health care resources |
| Usually involves data
collection, review and/or authorization, especially for services such as a
specialist referrals and emergency room use, and particularly costly services
such as hospitalization |
| Utilization Review ("UR") also known as
Utilization Management is the process by which the health plan, payor or UR firm
determine which services are medically appropriate and cost effective |
| Many
insurance plans and all HMOs require that UR procedures are followed prior to
all inpatient and some outpatient and emergency care or they will not pay for
services rendered |
|
Typically, Utilization Review (UR) involves UR coordinators who go through
patient’s chart after hospital admission to expedite care, avoid delays of
service, and to ensure the patient is being treated at the appropriate level of
care.
| Utilization Review aims to provide for effective pre-admission screening
to avoid unnecessary admissions and provide early discharge planning to promote
prompt placement once patient has reached a lower level of care |
Utilization Review aims to provide for effective pre-admission screening
to avoid unnecessary admissions and provide early discharge planning to promote
prompt placement once patient has reached a lower level of care. An example of
this is discharge planning in which the UR coordinator advises to move a patient
from a hospital to home health care when medically appropriate. The focus of
Utilization Review is on appropriateness, effectiveness and quality of services
provided.
| The focus of
Utilization Review is on appropriateness, effectiveness and quality of services
provided |
There are three types of utilization review:
prospective, concurrent and retrospective. Prospective review is
review or authorization for elective procedures or services prior to such
services being rendered. Concurrent review is review or
authorization for procedures or services during the time such services are being
rendered. An example of concurrent review is when a physician calls a
Managed Care Organziation (MCO) and requests an initial length of stay (LOS)
for a patient and then after the patient has been admitted into the hospital,
the physician calls the MCO and explains that due to extenuating circumstances
the patient needs to stay in the hospital for a longer time and the physician
requests an extended length of stay (ELOS). Retrospective review
is review of services after they have been rendered, typically using medical
charts. Most physicians, have learned through the years, to not have
retrospective review used as a source for payment by MCOs because hindsight is
always 100%.
Types of Utilization Review:
| Prospective |
| Concurrent |
| Retrospective |
|
The following is derived from Jeanne M. Madden, Ph.D., Stephen B. Soumerai, Sc.D, Tracy A. Lieu, M.D.,
et.al., “Effects of a Law Against Early Postpartum Discharge on Newborn
Follow-Up, Adverse Events, and HMO Expenditures,” The New England Journal
of Medicine (December 19, 2002): 2031
– 2038: