Utilization Review (UR): A Process for Health Care Quality Improvement
Utilization review (UR) has become increasingly important in the healthcare industry as a means of improving quality and care outcomes while containing costs. UR is a process that evaluates the appropriateness, medical necessity, and efficiency of healthcare services and treatments. This review helps to ensure that healthcare services meet established standards of care and are necessary for the patient’s condition. UR also helps to identify areas of potential cost savings and improve the quality of care. In this paper, we discuss the history, purpose, and components of UR, as well as its role in healthcare quality improvement and cost containment.
History
The concept of utilization review originated in the early 1900s when the American Medical Association (AMA) established a committee to review the appropriateness of medical treatments. In the 1950s and 1960s, the AMA and the American Hospital Association (AHA) developed standards and guidelines for utilization review. In the 1980s, the federal government began to require utilization review for Medicare and Medicaid services in order to control costs.
Purpose
The purpose of UR is to improve the quality of healthcare services and to ensure that services provided are medically necessary and cost-effective. Utilization review is also used to identify areas of potential cost savings, improve patient outcomes, and ensure compliance with accepted standards of care.
Components
Utilization review is composed of three main components: pre-authorization, concurrent review, and retrospective review. Pre-authorization is the process of evaluating a healthcare service before it is provided to determine if it is medically necessary and cost-effective. This process helps to ensure that the service is appropriate for the patient’s condition and that the provider is following accepted standards of care.
Concurrent review is the process of evaluating a healthcare service while it is being provided. This process helps to ensure that the service is being provided in a timely manner and that it is meeting the established standards of care.
Retrospective review is the process of evaluating a healthcare service after it has been provided. This process helps to identify areas of potential cost savings and ensure that the services provided were medically necessary and appropriate for the patient’s condition.
Role in Quality Improvement and Cost Containment
Utilization review is an important tool for improving healthcare quality and containing costs. By evaluating healthcare services before, during, and after they are provided, UR helps to ensure that services are medically necessary and appropriate for the patient’s condition. UR also helps to identify areas of potential cost savings and ensure that the provider is meeting established standards of care.
Conclusion
Utilization review is a valuable tool for improving healthcare quality and containing costs. By evaluating healthcare services before, during, and after they are provided, UR helps to ensure that services are medically necessary and appropriate for the patient’s condition. The process also helps to identify areas of potential cost savings and ensure that the provider is meeting established standards of care.
References
American Medical Association. (n.d.). Utilization review: History and development. Retrieved from https://www.ama-assn.org/delivering-care/utilization-review/history-and-development
Centers for Medicare & Medicaid Services. (n.d.). Utilization review. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Utilization%20Review%20(UR)
Snyder, S. (2020). Utilization review: What it is and why it matters. Retrieved from https://www.beckershospitalreview.com/healthcare-information-technology/utilization-review-what-it-is-and-why-it-matters.html