Utilization Review | Health Insurance

If your health insurance coverage provider has joined the swelling ranks of those who use a process called utilization review, you may get caught in the crossfire of one of the greatest workplace legal feuds on record if you become ill.

The idea behind utilization review is simple: By having an objective eye, usually an independent agency, take a look at your medical problem and approve or disapprove the things your doctor recommends, insurance companies can cut down on treatments that are unnecessary and expensive. The savings can then be passed along to the employers and employees who are finding it ever more difficult to pay for health insurance coverage.

Most physicians hate utilization review—for different reasons. Some feel the pain in their purses: Any process that prevents doctors from prescribing treatment significantly reduces the charges they can bill to your insurance company. And a number of doctors view utilization review as nettlesome bureaucratic padding—too often staffed with decision makers who know little about medical practice. But employers like utilization review. So lawyers have found a lucrative place for themselves in the middle of that opinion clash—routinely filing lawsuits on behalf of doctors, employers, and their insurance companies

Utilization Review and Insurance Coverage
Unless the legal feud over utilization review is settled, you should be particularly careful in making sure you understand what role it would play in your health care coverage if you became ill and needed to file a claim.

Here are some questions to ask to help you evaluate coverage:

Does my health insurance coverage include a provision for utilization review?

If so, who will perform the review? Will it be someone on the company’s staff? Someone on the insurance company’s staff? An outside agency?

What kind of professional credentials are required of the people who would review my doctor’s recommendations for treating me?

What methods does my health insurance coverage use to enforce its utilization review decisions? For example, some health insurance plans merely compile lists of doctors whose charges are habitually high and then try to talk them into exercising restraint. Others use more aggressive tactics, such as reducing by 25% the fees paid to doctors who fail to obtain permission from the insurance company before performing a treatment on a patient.

Do I have the option of electing to participate in a health insurance plan that doesn’t include utilization review? If so, will it cost me more to be covered by that plan?

If my doctor or I disagree with a decision made by a reviewer, would I have the option of rejecting the utilization reviewer’s decision?

Having this information is not likely to keep you completely out of the utilization review feud, but at least you will understand what is happening to you and what options you have if you get caught in it.