UTILIZATION REVIEW (“UR”)/QUALITY ASSURANCE (“QA”)/ UTILIZATION MANAGEMENT (“UM”) – Class 7

Why would physicians care about the Utilization Review (UR) and Quality Assurance (QA) provisions in a managed care contract they are considering entering into?

  • To determine if they are reasonable and feasible; and
  • May seek to receive adequate notice before any procedures are amended; and
  • To terminate contract if they do not accept any new procedure to be imposed

Physicians usually seek to see Utilization Review (“UR”) and Quality Assurance (“QA”) procedures in advance to determine if they are reasonable and feasible and they may seek to receive adequate notice before any procedures are amended and to terminate contract if they do not accept any new procedure to be imposed

Utilization Review and Quality Assurance

  • May provide for periodic review of cases either on a retrospective, concurrent or prospective basis to evaluate the utilization and quality of services provided. They may provide utilization and quality guidelines and impose penalties for noncompliance with such guidelines subject to appeal rights by provider and patient.
  • Providers usually seek to see Utilization Review (“UR”) and Quality Assurance (“QA”) procedures in advance to determine if they are reasonable and feasible and they may seek to receive adequate notice before any procedures are amended and to terminate contract if they do not accept any new procedure to be imposed.

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