The term “utilization review” in case management primarily refers to what?

Utilization review in case management primarily focuses on determining medical necessity, which involves assessing whether the services provided to a patient are appropriate and necessary based on established guidelines and standards of care. This process ensures that patients receive the right level of care for their condition while also considering the efficiency and cost-effectiveness of that care. By evaluating the appropriateness of treatments, practitioners can ensure that resources are used effectively, minimizing unnecessary procedures and reducing overall healthcare costs.

While evaluating patient eligibility for treatments, assessing the quality of care provided, and monitoring overall health trends are important functions within healthcare, they do not encapsulate the primary focus of utilization review. Utilization review specifically targets the justification of services based on medical necessity, making it a critical component of case management in ensuring that patient care aligns with best practices and regulatory requirements.