What is 'utilization review' in healthcare?

Utilization review is primarily concerned with evaluating the necessity and appropriateness of healthcare services that are being requested or delivered. This process helps ensure that patients receive care that is both medically necessary and cost-effective, ultimately aiming to improve patient outcomes while managing resource use effectively.

In healthcare systems, utilization review involves assessing whether the treatments, admissions, or procedures align with established guidelines for medical necessity, often focusing on the quality and efficiency of care. By conducting these evaluations, healthcare providers and insurers can make informed decisions about which services to authorize and determine the correct level of care required for patients.

This process plays a critical role in managing healthcare costs and ensuring that patients receive appropriate interventions while preventing unnecessary services that do not contribute to their health.