UTILIZATION REVIEW ACTIVITIES – Class 5

Utilization review is a collective term for the following activities:

  1. Precertification: prior to elective hospitalizations, surgical procedures, and certain diagnostic tests, evaluations are conducted against standard criteria for appropriateness before payment is authorized.
  2. Concurrent Review: This procedure is the formal review of continuing hospitalizations to determine whether the length of stay and any subsequent medical intervention is appropriate and consistent with good medical practice.
  3. Discharge Planning: To minimize length of hospital stay, the HMO arranges in advance for care to be received after the patient is discharged.
  4. Case Management: Systematic reviews are conducted to identify patients who, because of the severity of illness or intensity of service needed, are likely to require protracted hospitalization or intensive therapy. These patients are tracked to ensure that they receive the most appropriate and cost-effective care

Claims review and retrospective review are not part of utilization review, but they are ways to assure quality. An HMO will review claims for enrollee eligibility, appropriateness of service, proper billing, and appropriateness of referral. In retrospective review, the HMO looks at claims and encounter referral data to compare actual utilization against what was expected. This study reveals physician practice patterns, which can then be evaluated against norms to determine physician efficiency. This practice of physician profiling is useful in measuring and assessing quality.

HMO’s have utilization management departments usually run by medical directors with a staff of nurses and other doctors.

As quality has become a buzzword in health care, major scientifically based, process-oriented efforts at continuously improving quality have been initiated. Quality Assurance (“QA”) committees attempt to ensure high-quality, appropriate care. The goals of QA are educationally driven and outcome-based: structure and process are important only if they improve patient outcome and change physician behavior. Quality assurance focuses on providing “medically necessary” services.

There are significant problems of measuring necessity and quality, determining patient satisfaction, and interpreting outcome data, there are also ethical, confidentiality, legal and other issues.

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