What is the primary purpose of utilization review in healthcare management?

Utilization review plays a crucial role in healthcare management by primarily focusing on assessing the medical necessity of care provided to patients. This process involves evaluating the appropriateness, medical necessity, and efficiency of the healthcare services provided. The goal is to ensure that patients receive care that is clinically justified and aligned with established guidelines, ultimately promoting effective use of healthcare resources.

By assessing medical necessity, utilization review helps to determine whether the proposed treatments or procedures are essential for the patient's condition, which can help prevent unnecessary or excessive interventions. This focus on medical necessity is also pivotal for controlling healthcare costs and ensuring that both patients and providers are engaging in value-driven care.

While improving patient outcomes is certainly an important aspect of healthcare management, the primary function of utilization review specifically targets the assessment of care appropriateness rather than the direct improvement of outcomes. Additionally, handling billing disputes and gathering patient satisfaction data are important tasks within healthcare administration but do not encompass the central role of utilization review. Therefore, the essence of utilization review lies in its focus on evaluating the necessity and appropriateness of healthcare services.