Utilization review helps determine if healthcare services are being used efficiently and appropriately to provide patients with the care they need. It also ensures that healthcare is administered through proven methods, delivered in the right setting, and provided by an appropriate healthcare provider.
Utilization reviews can be completed by health insurance companies, home health companies, and hospitals, among other healthcare providers. Sometimes, a utilization review may be completed as part of the prior authorization process when a patient requires approval from a health insurer before beginning a test or treatment.
For hospitals to participate in Medicare or Medicaid, the government requires they have an effective utilization review program.