What is a Utilization Review?

Where does Utilization Review fit in the insurance web

Utilization Reviews (UR) are used by health insurance carriers as a type of managed care to ensure that medical treatments are appropriate and efficient. Medicare may require a Utilization Review to verify that patient is not being over-prescribed pain medication. Worker's Compensation carriers may request URs to ensure that patients are not being over-treated by shady doctors. Your private insurance may require a Utilization Review to ensure that all first-line or recommended treatments have been attempted. Utilization Reviews are retrospective--that is it's a review of treatments that already have happened--but may be required before carriers provide prior authorizations for new services.

Utilization Reviews have strict criteria and rely on evidence-based evaluations. Your own doctor will submit the medical history, evidence, and recommendations and the insurance carrier will assign a neutral doctor to review the paperwork, evidence, and treatment plan before issuing their own recommendation. Insurance carriers could use that doctor's recommendation to decide to grant or deny a prior authorization. They can also use the results of URs to deny payment for treatments that may have otherwise been covered.

Utilization Review approvals are very specific. They will authorize treatment or medication with a specific time frame--sometimes as short as fifteen days, sometimes as long as a year. In some states, the recommendations and approval time-frames are controlled by state-law, and in other jurisdictions, the insurance carrier has full discretion of what to allow.

UR decisions are not necessarily set in stone. Treatments approved one month may be denied the next, or vice versa. Some UR denials can be appealed with additional supporting evidence, and other times the carriers will refuse to consider an appeal. However, once a utilization review has been appealed and the denial stands, legally the insurance carrier is not obligated for any services rendered after the denial date.

It's important to understand what your rights and responsibilities are when it comes to URs and prior authorizations, especially if your treatment plan includes pain management or specialty medications. Some providers will submit appeals on your behalf, while others may not have the interest or the means to do so.

If you've been left alone to understand the Utilization Review response or to try to submit an appeal for approval, we can help. We can explain what the insurance carrier has decided and the reason given for that decision. We may be able to help you gather the evidence and submit the necessary appeal for medical services. Contact us today to find out what we can do to help you now.

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