Utilization Review (UR), or Utilization Management, is a critical function to managing the quality and cost of care at any healthcare facility. Besides being a legal requirement for participation in federal healthcare programs (per 42 CFR § 482.30 – Condition of participation: Utilization review), it is crucial for preventing claim denials, keeping track of coverage rules and regulations, and preventing the misuse or overutilization of services.
Utilization management in behavioral health contexts is particularly important. Consider the opioid epidemic, which brings attention to addiction therapies and reimbursement. Despite their proven effectiveness, pharmacotherapy solutions for addiction treatment have been slow to adopt. [i]Access is often limited by prior authorizations and annual limits, [ii] and although the trend has been moving towards greater acceptance, insurance providers have more they could be doing to improve access. [iii] In addition to medication, the amount of time that patients stay at a facility also has an impact on therapeutic outcomes.