Utilization Review and the Practice of Medicine

The chief medical director should be the driving force of the UR, because the Chief medical director has the capability to check every department heads periodically and to assess healthcare on the source of relevance, need, and quality. 

Reference:

Utilization Review Committee - Resource Management Operations: https://www.youtube.com/watch?v=6vpUB6HCnrM

Bryan Cerritos

The Utilization Review Process is an unfortunate side-effect of rising healthcare costs over the last few decades (The Utilization, 2018). Due to rising costs, as well as questions concerning quality of care, a number of “checks & balances”, such as Utilization Review (UR), have been developed and put in place as mitigating solutions to these growing problems (The Utilization, 2018). UR, a process that refers to the review of care based on medical necessity, is a health insurance spearheaded process that seeks to keep medical costs under control and also prevent fraud (Jeffries, 2007). In short, this process often involves the review of past medical treatment and current medical standards for the preauthorization and approval of future and/or ongoing medical care (Jeffries, 2007).

At face value, it would seem that insurance companies are in-fact “practicing medicine” through the UR process. After all, UR often includes the review of treatments or services that have been administered, review of medical files, the review and approval of treatment guidelines, and even a review and audit of patient experiences of how providers, staff, and the hospital in general handled the overall healthcare process (Jeffries, 2017). Yet, the reality of UR is that it is simply an administrative process. There is no “first-hand” contact with patients and/or providers. The insurance company is not dictating what should or should not be done to and for the patient incessantly. The UR process is more of an oversight, and completely dictated by the terms set forth by the contract said provider/institution entered into with the insurance underwriter. Nothing is done outside the confines of this agreement unless either party wishes to incur legal ramifications.

With that said, the UR process should and needs to be governed by a body experienced in medical care. It makes no logical sense, and can almost be viewed as negligent, that a person or body not experienced in first-hand healthcare would be solely responsible for designing, approving, and executing such UR processes. Suffice it to say, that providers and healthcare institutions would not enter into such contracts in the first place. The individual or group that oversees the UR process should be very experienced in the healthcare process, possibly a former provider, and also be apprised of the latest innovations, developments, and trends in healthcare in general. They are here not only to ensure the efficient and lawful use of healthcare resources, but also to ensure positive healthcare outcomes.

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