Government Utilization Review Guidelines

Governments must be accountable to taxpayers.

Seeking quality medical treatment is a necessity for most people. Workers, employers, insurers and medical facilities all play a critical role in seeking, facilitating and offering proper medical treatment. Government utilization review guidelines are processes which ensure that medical facilities operate properly and patients receive proper treatment.

Terms

The law requiring utilization review went into effect Jan. 1. 2004, and applies to all medical treatment being offered. The claim administrator does the review and makes a decision within five days of the date treatment was requested by a physician. The claims administrator can have up to 14 days by virtue of "prospective review" because it is done before you get the treatment.

Guidelines

Given that the health care sector is complex and difficult to micromanage, government guidelines on utilization review are broad and cover different health-related concerns. The overall aim is to protect consumers from improper health care and insurance practices.

Standards

Although the government instituted utilization review guidelines nationwide, regulations vary by state. State and federal agencies define the guidelines differently and every state approaches the issues of implementation differently. However, health care utilization review organizations (UROs) and other national bodies such as the Utilization Review Accreditation Commission (URAC) work with the government to oversee accreditation and implementation of the guidelines.

References

• City Of Fresno: Answers To Your Questions About Utilization Reviews
• Washington State Department of Labor and Industries: Utilization Reviews
• Urac: What is Accreditation
• American College of Occupational and Environmental medicine Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, Third Edition