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What is Utilization Review?

Utilization review is a process used by healthcare payers and providers to evaluate the appropriateness and necessity of medical treatments and services. The goal of utilization review is to ensure that a patient receives the levels of care most suitable to their treatment needs for the duration of time deemed necessary by their treating provider. The process is typically performed by a team of healthcare professionals who are specifically trained to evaluate and advocate for these determinations based on the guidelines and criteria established by the payer or provider.

The Importance of Utilization Review

The importance of utilization review cannot be overstated. It is the link between the patient, the provider, and the insurer that enables the patient to receive the proper level of care for the appropriate amount of time.

Unfortunately for the patient, there is often a desire on the insurer’s part to minimize the clinical hours that a client receives. Utilization review functions by advocating for a patient’s specific treatment needs in the face of the insurer’s propensity for money-saving tactics. Here at AHS, we mobilize our compassion for the patient by working to ensure their best chances for recovery are not being curtailed or compromised by an insurer’s aggressive push for cost-effectiveness.

Without this integral part of the process, all decisions regarding the clinical care of the patient would be left vulnerable to cost reduction efforts at the hands of individuals not intimately familiar with the patient’s case.

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