Why Independant Medical Reviews?

Most private or public health insurers paying for patient care require some form of independent medical review to decide the need and appropriateness of a proposed medical treatment.  To protect consumers, most states and many federal regulatory agencies require it.  How these reviews are administered affects nearly every person enrolled in a private or government funded healthcare plan.  Typically, payers and doctors call them utilization reviews or utilization management reviews.

Although administrators and doctors often use the two terms interchangeably, utilization review is the older term and has broader meaning than utilization management.  It’s a more generic phrase that encompasses utilization management.  Government and state insurance commissions use the phrase utilization review to create consumer healthcare protection.  Legal decisions on patient care cite utilization review and not utilization management.

To sort out the confusion, let’s clearly define the two ideas and then apply them to medical management and utilization management firms, as well as independent review organizations (IROs).

Read more about the role of IROs and Medical Management Companies in this Utilization Review Guide by filling out the form on the right.