Utilization review: theory, practice, and issues.

Area of Science:

• Healthcare Management
• Health Services Research
• Quality Improvement

Background:

• Utilization review (UR) is widely implemented across healthcare settings, including hospitals, agencies, payers, and private companies.
• Despite its prevalence, practical explanations of UR processes remain scarce.
• Existing literature often lacks comprehensive details on developing and executing UR systems.

Purpose of the Study:

• To provide a practical guide to utilization review processes.
• To differentiate between internal and external UR and their outcomes.
• To outline the development, stages, and levels of UR systems.

Main Methods:

• The guide differentiates internal and external utilization review.
• It outlines the development of a utilization review system.
• It describes the stages and levels of review.

Main Results:

• Psychiatric utilization review presents unique difficulties, often limited to assessing hospitalization necessity and duration.
• General utilization review faces persistent challenges concerning patient confidentiality.
• Ethical considerations include the clinical responsibility of reviewers and potential for inappropriate care to be incentivized.

Conclusions:

• A clear understanding of UR processes is crucial for effective healthcare management.
• Addressing challenges in psychiatric UR and general UR issues like confidentiality is essential.
• Ensuring ethical practice in utilization review is paramount for quality patient care.