Utilization Review

Updated: 11 March 2024

What Does Utilization Review Mean?

A utilization review is an investigation of health care services, treatments, and facilities performed by a doctor or a nurse. The purpose of these reviews is to make sure that health insurance companies are not wasting any money covering things that are unnecessary for proper treatment or inefficient.

Insuranceopedia Explains Utilization Review

Utilization reviews are essentially a way for health insurance companies to monitor healthcare services. If an important discovery is made during a utilization review, then it may affect how a health insurer writes future policies. For example, if a utilization review discovers that a particular doctor is charging 30% more for comparable procedures, then the health insurance company may chose not to cover him anymore. Utilization reviews must be performed by qualified individuals to be legitimate.

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