The Utilization Review Program

Abstract

The survival of a health care institution in today's economic climate is dependent on, among other things, the efficiency of its utilization review pro gram. The purpose of this article is to serve as a basic guideline for an institution to develop an adequate utilization review program. It emphasizes that a uti lization review program is essential for the economic survival of any health care industry. The utilization review program should be an integrated organization with the support of administration, and the partici pation of staff physicians, physician advisors, review nurses, and important hospital departments, such as social service, laboratory, medical records, preplan ning, and so forth. Following the format presented in this paper, an institution may easily develop a utili zation review program. The ideas presented in this paper have been time-proven at our institution.

There must be educational programs for physicians on the basics of managing patients according to the prospective payment system and the economic impact physicians can make on the hospital's economic sta tus. These educational presentations must take place as often as necessary to reinforce policy and proce dure, and to carry out effective patient management.

The utilization review department, as well as the medical staff, must work in close harmony with ad ministration to assist the facility in surviving trying economical times.