Definition of Utilization Review
A utilization review is defined as a process for monitoring the delivery, use and cost-effectiveness of services, especially those that are provided by medical professionals. It is the critical examination of health-care services that are provided to patients, especially for the purpose of controlling costs and monitoring the quality of care. As it applies to workers' compensation, a utilization review is a review of the medical appropriateness and necessity of the medical care and services that an injured worker receives for their work-related injury or illness. Put simply, a utilization review makes sure that the treatment an injured worker receives is consistent with the medical treatment guidelines that have been set by the state.
An injured worker's employer or their employer's insurance company uses the utilization review to determine whether or not to approve and pay for the medical treatment that is recommended by an injured worker's treating doctor. If an injured worker does not agree with the utilization review, it can be challenged and appealed. The procedure and time limit for doing so varies from state to state. If an injured worker decides to appeal their utilization review, it is always a wise idea for that worker to be represented by a workers' compensation attorney.