What is the primary purpose of a utilization review?

The primary purpose of a utilization review is to ensure medically necessary care is delivered. This process involves evaluating whether the healthcare services provided to patients are appropriate in terms of necessity, effectiveness, and efficiency. By focusing on the medical necessity, utilization review helps to maintain quality care standards and prevent unnecessary treatments, which can lead to increased healthcare costs and potential harm to patients.

In the context of healthcare management, utilization review serves as a critical tool to ensure that patients receive the right level of care for their specific conditions. It assesses clinical decisions and ensures that the treatments align with established guidelines and protocols, contributing significantly to the overall effectiveness and economic sustainability of healthcare services.