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Utilization Review

What is utilization review?

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.


How do utilization reviews improve healthcare?

When the utilization review process is complete, it should result in higher quality care administered as economically as possible. Additionally, the practice should align with current guidelines for evidence-based care.

The ultimate goal of a utilization review is to ensure a patient is receiving the best possible care. It can also impact whether or not a patient’s claims are covered, affecting how much the patient pays for healthcare services and which services they receive.