Effect of Utilization Review in a Fee-for-Service Health Insurance Plan

Most health maintenance organizations and over 90 percent of health insurance plans review the provision of health care to their enrollees in order to control costs. 1 – 4 Numbers of hospital admissions and days of inpatient care have been shown to decrease when such monitoring, known as utilization review, is introduced. 2 – 12 The reductions may be due to one or more of the changes that utilization-review programs strive to accomplish, including the use of ambulatory surgery and outpatient treatment for psychiatric disorders or substance abuse instead of inpatient care, preadmission testing instead of preoperative hospitalization, and home care instead of extended . . .