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AllMed’s Skip Freedman Compares Utilization Review & Utilization Management
Added: 01/27/2006
 Type: Summary
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AllMed’s Skip Freedman Compares Utilization Review & Utilization Management

 Dr. Skip Freedman of AllMed Healthcare Management has a featured article “Understand the Nuances of Utilization Review and Utilization Management” in the most recent issue of Managed Healthcare Executive Magazine. The article may be viewed by clicking the following link: http://www.managedhealthcareexecutive.com/mhe/article/articleDetail.jsp?id=282713

URAC defines Utilization Review and Utilization Management differently. Utilization review is the process of reviewing medical cases after they are concluded. Utilization management is “the evaluation of the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities under the provisions of the applicable health benefits plan.” Over time, many people have begun to use the term “utilization review” when they actually mean “utilization management”. In actuality, “utilization management” is a subset of “utilization review”.

Across the country, different states and government agencies define these rules differently. It is the job of an Independent Review Organization (IRO) to keep update with these conflicting rules and regulations, to make sure that the medical treatments are “medically necessary”, meet mandated response times, and conform to the payors health insurance plan.
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