Utilisation review is a process that is conducted by a Health Insurance company when it reviews a request for medical treatment. Through this process, the insurance company can process the entire plan offered - and try to somehow reduce the costs. It also gives the customer the opportunity to explore the health plan and file a legal complaint if the health insurance does not agree.
Utilisation review is sometimes confused with utilisation management. Utilisation management is with respect to approval of future needs and utilisation management is for review of past records and medical treatment.
Utilisation review is also called retrospective review. It reviews the following:
a. The treatment services that have been used and prescribed by the doctors.
b. The relative comparison between the past treatment file and guidelines.
c. The records also serve as a database for the Medical Insurance company - that helps it to make decisions. All the stakeholders involved the process - patient, nurses, doctors, insurance agent - give on their feedback and perspective, that is also documented.
Example of a Utilisation Review Plan - The Layout and Topics covered
1. Objectives - Set the aim of the review
2. Scope - Set the limits and defined boundaries for the process
3. Peer Review
4. Conflict of Interest - physician who is in charge of the process will not participate in the review