** Concurrent
utilization reviews allow pharmacy benefit managers to alert dispensing pharmacists to question a prescription if there are indications of abuse, including the use of multiple pharmacies and physicians for different narcotics or excessive early refill attempts.
* A retrospective drug
utilization review process takes place after medications are filled.
Whereas the
utilization review file will reveal the decision-making involved in authorizing or denying care for the insured, the underwriting file will demonstrate what type of coverage the insured sought when entering the HMO plan.
The effect of decreasing
utilization review has varied from plan to plan, Ms.
Utilization review is the process that insurance companies use to determine that a recommended medical treatment or procedure is medically necessary (Public Policy & Education Fund of New York, 1997).
Through the use of data from one well-established UM firm, we conducted an exploratory analysis of the effect of prospective
utilization review on hospital inpatient care for patients with cardiovascular illness.
Before making the decision to end
utilization review, UnitedHealth Group ran a pilot project that cut that division from 6 member health plans.
Bills introduced by Republicans this year would authorize invasion of patient records by health care "entities" carrying out "health care operations?' S 881 and HR 448 define "health care operations" to include a smorgasbord of vaguely described activities, including "
utilization review," "coordinating health care," and "conducting quality assessment and improvement activities." Similarly, S 578 says "health care operations" includes "
utilization review," "management functions of a health care provider or health plan," and, for good measure, "services the Secretary [of HHS] determines appropriate."
Utilization review committees began to look at whether the duration and frequency of service was medically necessary.
Merging of functions that once were separated by departmental boundaries and administrative reporting relationships e.g.,
utilization review, discharge planning, quality review, precertification, and case management is now becoming commonplace.