Utilization review

Utilization management (UM) is defined by the Institute of Medicine (IOM) Committee on Utilization Management by Third Parties (1989) as "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision."

UM is the evaluation of the appropriateness and medical need of health care services procedures and facilities according to evidence-based criteria or guidelines, and under the provisions of an applicable health benefits plan. Typically, UM addresses new clinical activities or inpatient admissions based on the analysis of a case, but may relate to ongoing provision of care, especially in an inpatient setting.

UM describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews as well as appeals introduced by the provider, payer or patient. A UM program comprises roles, policies, processes, and criteria.

UM roles may include: UM Reviewers (often an RN with UM training), a UM program manager, and a Physician Adviser. UM policies may include the frequency of reviews, priorities, and balance of internal and external responsibilities.

UM processes may include escalation processes when a clinician and the UM reviewer are unable to resolve a case, dispute processes to allow patients, caregivers, or patient advocates to challenge a point of care decision, and processes for evaluating inter-rater reliability amongst UM reviewers.

UM criteria may be developed inhouse, acquired from a UM vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria, and the Milliman Care Guidelines (Milliman is now known as MCG).

Similar to the Donabedian healthcare quality assurance model, UM may be done , , or .

Prospective review is typically used as a method of reducing medically unnecessary admissions or procedures by denying cases that do not meet criteria, or allocating them to more appropriate care settings before the act.

Concurrent review is carried out during and as part of the clinical workflow, and supports point of care decisions. The focus of concurrent UM tends to be on reducing denials and placing the patient at a medically appropriate point of care. Concurrent review may include a case-management function that includes coordinating and planning for a safe discharge or transition to the next level of care.

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