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Utilization Reviews: An Introduction

By AGS Health

June 27, 2023

Utilization reviews, also known as utilization management, is used by insurance companies and healthcare providers to evaluate the necessity and appropriateness of medical treatments and services. During a review, recommendations for alternate care or treatment may be made to help manage the cost of healthcare benefits. The process uses evidence-based criteria or guidelines. The goal is to ensure patients receive the care they need while controlling costs and avoiding unnecessary procedures.

Types of Utilization Reviews

There are several different types of utilization review including:

Precertification Concurrent Review Retrospective Review

Occurs when a healthcare provider requests approval from an insurance company before providing a specific treatment or service.

Occurs when a healthcare provider requests approval for a treatment or service while the patient is still receiving care.

Occurs when an insurance company reviews a patient's medical records after treatment is completed.

Who Performs Utilization Reviews?

Typically, utilization reviews are performed by healthcare professionals, including doctors, nurses, and case managers. They will review the patient's medical records and evaluate the proposed treatment or service to determine if it is medically necessary and appropriate. They will also consider if alternative treatments would be more cost-effective.

Downsides of Utilization Reviews

There are some downsides to utilization review. Some healthcare providers may feel the review process is burdensome and time-consuming. Additionally, there is the risk that the utilization review may delay or deny necessary care to patients.

Top Four Benefits of Utilization Reviews

  1. Improved Patient Outcomes: Patients receive the most appropriate care for their conditions, which leads to better patient outcomes and reduced complications.
  2. Cost Control: Reviews identify and reduce unnecessary procedures and treatments, which controls healthcare costs.
  3. Compliance with Regulations: Helps healthcare providers comply with regulations and guidelines for medical treatment and reimbursement.
  4. Quality Assurance: Can be used as a quality assurance tool to help providers evaluate and improve the quality of care they provide.
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Conclusion

While utilization reviews can help ensure patients receive the most appropriate care and control healthcare costs, balancing these benefits with the potential downsides is vital to ensure patients receive timely care.

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AGS Health

Author

AGS Health is more than a revenue cycle management company–we’re a strategic partner for growth. By blending technologies, services, and expert support, AGS Health partners with leading healthcare organizations across the US to deliver tailored solutions that solve the unique needs and challenges of each provider’s revenue cycle operations. The company leverages the latest advancements in automation, process excellence, security, and problem-solving through the use of technology and analytics–all made possible with college-educated, trained RCM experts. AGS Health employs more than 10,000 team members globally and partners with more than 100 clients across a variety of care settings, specialties, and billing systems.