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Introduction to Quality Insurance

Utilization review implies the process which is specially designed towards the provision of the most appropriate and adequate medical attention available to a patient in the most appropriate manner. Its basic aim is to evaluate the broad necessity held by medical plans. According to this framework, medical necessity is synonymous to the needs for supplies, services, care and any treatment which a person receives over physical injury, ailment, disease or a condition. Such treatment and services should adhere to medical professionalism in terms of qualified healthcare standards.

This is perhaps why utilization review is a benchmark process in practicing medicine. All the health care standards under UR should be able to meet the medical objections of reducing, slowing and eliminating the different impairment that result from disease, condition, injury or ailment. (http://64. 85. 16. 230/educate/content/development/utilizationreview. html) The basic idea behind UR is to monitor the level of appropriateness in the hospitalization process of patients while in hospitals. Due to the delicacy of the medical care process, UR should have the necessity of limitation to those practicing medicine.

Only professional and licensed medical practitioners should have the authority of undertaking UR. This is because of the broad medical professionalism which is perhaps the guiding formula towards a satisfactory conception of UR, since licensed practitioners are by virtue bestowed with practicing license following medical professional attainments. Such can only be worth of performing varies medical activities that ensure the most appropriate state of health care monitoring in the hospitalization process of the patients.

Unlike the current order that UR can even be performed by different third party persons who are by virtue the payers of the hospitalization bill, such parties may lack the professional competence of ascertaining the most appropriate level of attention worth for their patients. However the hospital department for UR should be headed by a qualified and licensed medical practitioner who then transfers such information to the third parties. The exercise of incorporating licensed medical profession in the UR process is perhaps the foremost benchmark process towards giving an initiative for patient’s safety.

This is largely provided by the virtue that medical practitioners follow the accredited rules jurisdictions which are guided by the professional formulas that they acquired in their professionalism. (http://64. 85. 16. 230/educate/content/development/utilizationreview. html) Since the UR process in an important tool for understanding the basic relationships existing between the different parties in to the process, optimum satisfaction and relationship can only be linked to the affirmative UR results by a licensed and qualified medical practitioners.

On the side of the payers, they have the basic interest of providing the most optimal protective tool to their patients through medical services and necessity. Their goal could be comprised if the UR process was done unprofessionally which would negative their positive motive of their patients in the medication process. Elsewhere, the hospital desires the most appropriate payment for the services given to the patients. However, optimal service payments can only be balanced whenever adequate services and medication are given to the patients.

Otherwise if an imbalance exists between the medical status and the amount of payment between the medical status and the amount of payment, there would arise professional conflict between the patient, the hospital and the payers. As an overall effect, qualified medical practitioners are only subjective to performing their work professionally to reduce such conflict. (http://64. 85. 16. 230/educate/content/development/utilizationreview. html)

Over and above the role of the physician in administering the medical attention to patient that agrees with the motives of the payers and hospitals should not be compromised. However, it is only qualified practitioners who can adjudicate the most appropriate and best medical attention that reduces the epilog of conflict between the different parties into the UR process. These are the licensed medical practitioners.


Utilization Review. Retrieved on 7th May 2008 from http://64. 85. 16. 230/educate/content/development/utilizationreview. html

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