Utilization Review and Medical Necessity in Healthcare

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Paper Topic: Utilization Review and Medical Necessity in Healthcare Running Head : UTILIZATION REVIEW Utilization Review and Medical Necessity in Healthcare [Name of Author] [University /Institution] Utilization Review and Medical Necessity in Health Care There are two trends which are shaping how health care is being managed in the country as manifested in the actions of providers and medical practitioners One trend is the use of utilization review which includes presentation prospective and simultaneous review system in the allocations of health care resources evaluated for necessity and appropriateness of corresponding services

The term medical necessity whenever used in the medical profession is taken in the context of evaluating or treating patients , out of the necessity of providing medical care Medical necessity however has been equated with the catchphrase at the lowest cost ‘ raising the concern that third party payer are basing their payments on medical necessity determination which lowers the standard of medical service being provided Medical necessity is also directly related to health care products or services including diagnosis and treatment of specific illness , symptom complaint , or an injury

Utilization review also covers medical health care services and specific surgery services that are supposed to be given to the patients that may possibly be covered by a health care insurer The health care insurer reviews the availability of contract benefits and applies clinical guidelines to medical circumstances of individual patients

An undesirable decision may result in such a manner with the patient foregoing the recommended procedure altogether because the basis of decision is according to the provision of the insurance or health care package and not on the medical conditions of the patients A utilization review judgment is most often based on clinical guidelines

The medical situation of insured patients should be considered at the time the service or supply is rendered and should not be based on the criteria for convenient indemnification of the medical provider

Most medical programs consider only health care items and services that are necessary for improving or maintaining the beneficiaries ‘ health

Through time , the practice has spread and is becoming the standard in the health care industry Medical necessity meanwhile , means diagnosing or treating an injury or sickness to the required extent

After the review , physicians are informed of the results and encouraged to make judgments from the perspective of medical necessity and not according to terms stipulated in the health coverage

It is the shortest , the least intense and inexpensive level of treatment , care or rendered services

Its main point is to provide health insurance br and governing regulations with the vision of providing universal coverage

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