What does 'utilization review' involve?

Utilization review is a critical component of healthcare management, focusing on evaluating the necessity, appropriateness, and efficiency of the use of healthcare services. Its primary goal is to ensure that patients receive appropriate care while also managing costs and resources effectively.

This involves looking closely at the medical necessity of proposed treatments and interventions, determining whether they match established clinical guidelines and standards of care. By conducting these evaluations, healthcare providers aim to avoid unnecessary procedures, which can lead to better health outcomes for patients and reduced financial strain on the healthcare system.

In contrast, denying claims based on policy exclusions does not involve a thorough examination of the care itself but rather operates within the parameters of coverage policies. Assessing patient satisfaction, while important, does not address the appropriateness or necessity of healthcare services. Similarly, enrolling patients in managed care plans is a logistical function and does not pertain to the evaluation of service utilization. Thus, the essence of utilization review resides in the careful scrutiny of healthcare services to align them with clinical needs and best practices.