Understand the nuances of utilization review and utilization mangement

January 1, 2006

Healthcare managers, administrators and doctors often confuse the phrases "utilization review" and "utilization management." The healthcare business uses the two interchangeably, however understanding their nuances helps clarify their meaning.

According to URAC (formerly the Utilization Review Accreditation Commission), a nonprofit organization promoting healthcare quality by accrediting healthcare organizations, utilization review portrays the review of cases after healthcare services are conducted. Some Medicare work today is after the fact and may be called utilization review.

With the precertification and concurrent review of cases, utilization review morphed into utilization management. URAC defines utilization management as "the evaluation of the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities under the provisions of the applicable health benefits plan."

SAYING WHAT YOU MEAN

Still, URAC recognizes that sometimes many of us say utilization review when we mean utilization management. Utilization review is the older and more generic phrase that now encompasses utilization management. Legal decisions on patient care cite the term. Government and state insurance commissions use it to establish consumer healthcare protection. Both use broad, nonspecific language, because it's possible to reinterpret legal precedents or regulations to expand consumer protection without rewriting the regulation.

State and federal governments may look to URAC and similar standards organizations as the basis for their consumer protection and may even refer to these standards. But government's role is two-fold. First it declares that there will be utilization review controls to protect consumers from arbitrary, capricious and misleading information about healthcare services, treatments, practices and procedures. Then it tells health organizations what standards it expects.

Unfortunately each state and even federal agencies define the "rules" differently. Governmental groups, such as state insurance commissioners, usually set up the need and define their own guidelines-and every state approaches the issue differently.

Each sets up differing responsibilities for healthcare organizations to meet, such as timing, formats for reporting, who needs to be notified and what needs to be reported. All meet the declared standard, yet each has different requirements. This creates a jumble of differing utilization review requirements that healthcare organizations operating in several states must understand and meet.

To help maintain high-quality utilization management standards, organizations like URAC accredit healthcare organizations to meet the needs of federal and state governments. As a standards organization, URAC is purposely specific in its language. Its standards give providers and other organization an encompassing set of guidelines to follow. Using these, providers communicate the level of utilization management needed to their staff and healthcare consumers.

By observing these, they can also show regulatory bodies that they comply with the mandated standards. Once accredited, URAC holds the organization accountable to that standard of utilization management.

INVOLVEMENT OF IROS

Independent review organizations (IROs) are an example of this accreditation. By accrediting an IRO, URAC attests that it conducts utilization reviews that follow current clinical practices, respect patients' and providers' rights and comply with any regulatory needs and deadlines. It requires IROs, and other organizations, to continue meeting these standards through regular reaccreditation to keep healthcare quality high and stay current with new procedures and practices.

For its part, the IRO must conduct its business in a way to ensure any procedure is medically necessary, conforms to the payer's healthcare plan and meets mandated response times.

Part of an IRO's due diligence is keeping up with all the state and federal mandates-an effort that makes it easier for national organizations to meet the mish-mash of requirements for utilization review.

Skip Freedman, MD, is the medical director at AllMed Healthcare Management, an independent review organization based in Portland, Ore. Dr. Freedman is also an emergency room doctor and practices at several hospitals in the Portland-Vancouver Metropolitan area.