What is the main function of utilization review?

The primary function of utilization review is to determine medical necessity for services provided or proposed. This process involves examining the appropriateness of certain healthcare services, ensuring that they are necessary and in accordance with established guidelines and standards of care.

Utilization review contributes to overseeing the quality of care by assessing whether the treatments being received or recommended align with accepted medical practices. It helps ensure that patients receive appropriate care while avoiding unnecessary procedures or treatments that could lead to increased healthcare costs or potential risks to patient health.

Focusing specifically on medical necessity, the review process evaluates the reasons for the proposed services and whether they are justified based on clinical evidence and guidelines. This not only supports patient care but also serves as a mechanism for insurance companies to manage costs and maintain efficient resource allocation within the healthcare system.

Other aspects of healthcare management, like approval of all proposed services or providing emergency service coverage, are important but not the primary focus of utilization review. Additionally, while evaluating cost-effectiveness may play a role in certain programs, the central aim of utilization review remains the verification of medical necessity above all.