Insight

Simply speaking, Utilization Review is a process whereas Utilization Management is a program.

Utilization Review (UR) is the action of evaluating and validating the medical necessity and appropriateness of medical services, such as treatments, procedures, medications, and inpatient stays. Unlike, Utilization Management, the UR process validates appropriateness of care and identifies quality of care issues; whereas, UM measures outcome of UR activities and reacts to identified issues by implementing policies and developing performance measures.

UR is performed to help avoid the use of unnecessary and inappropriate medical services. The UR process allows organizations the ability to validate the need for medical services. Typically, Registered Nurses perform the UR process. However, other licensed clinicians, such as licensed vocational nurses, clinical psychologists, physical therapists, etc., are also known to perform UR roles. Nurses are widely used in UR roles because of their understanding of patient care and hospital processes. UR clinicians use pertinent clinical documents such as physician notes, test or procedure results, therapy notes, etc. to evaluate the medical need and appropriateness of a service, level of care, or discharge disposition. UR clinicians access evidence based clinical guidelines/criteria, licensed and/or established by their organization to review these documents and evaluate the necessity of proposed, ongoing, or rendered services. In addition, organizations may use Independent Review Organizations (IROs) as an adjunct to their UR function or as secondary review entities to help ensure objective and unbiased reviews are performed. 

There are three types of review in the Utilization Review process:

Prospective (aka: prior authorization, pre-certification, pre-service)

A review process in which clinical information and service requests are reviewed to determine medical necessity before services are provided. Review determinations are based on the medical information available and obtained at the time of the review.  

Concurrent

A process of reviewing the medical necessity of an admission and ongoing inpatient stay while a patient is currently in the facility. Facilities such as acute care, skilled nursing, subacute, and acute rehabilitation may be subject to the concurrent review process. Concurrent review is performed by evaluating available clinical documents. And equally important, through verbal communication with hospital or facility case managers, discharge planners, physicians and other involved healthcare professionals, and as appropriate, with the patient.

Retrospective (aka: post-service)

A review process in which clinical information is obtained to determine medical necessity after services were provided. This generally occurs when:

• There was no notification or request for review during the prospective or concurrent process
• Clinical documents were unavailable at the time services were rendered and the timeframe to obtain or submit the supporting documents ended.
• Provider was unaware the patient was a member of a health plan that required prospective review for rendered services.

Utilization Management (UM) is a program and the basis for Utilization Review (UR) activities. The core principle of UM programs is to measure and continuously improve the effectiveness an organization provides services while maintaining quality, cost effective care. UM programs are implemented by hospitals, clinics, health plans to support and address UR activities. While the UR process validates appropriateness of care and identifies services that are outside the scope of practice, UM ensures healthcare systems continuously improve quality of care and deliver appropriate levels of care. Thus, reducing the risk and volume of cases that need UR for inappropriate or unnecessary care.
UM programs are designed to promote the delivery of high quality, medically necessary, and cost effective health care services. Through UM, operational policies and procedures are developed to improve the outcome of the review process and the quality of healthcare services. In addition to the Utilization Review process, UM programs may include these components:

• Developing UR performance metrics, such as consistency of decision-making, accuracy of review, timeliness of decisions.
• Monitoring, measuring, and evaluating the effectiveness of UR activities
• Identifying services that are over or under utilization
• Ensuring UR activities meet regulatory standards
• Evaluating if medical costs are managed effective
• Improving communication between payers, providers, and insurers
• As appropriate, performing clinical and claims review of service appeals