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Utilization review: theory, practice, and issues.

J Zusman1

  • 1Florida Mental Health Institute, Tampa 33612.

Hospital & Community Psychiatry
|May 1, 1990
PubMed
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This guide explains utilization review (UR) processes in healthcare, differentiating internal and external reviews. It addresses challenges in psychiatric UR and ongoing issues like confidentiality and reviewer responsibility.

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.

Related Experiment Videos

  • 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.