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Whodunit? Causal Responsibility of Utilization Review for Physicians' Decisions, Patients' Outcomes

Published online by Cambridge University Press:  29 April 2021

E. Haavi Morreim
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Extract

In the “olden days,” only a few years ago, physicians were free to order virtually any service they believed their patients needed, confident that virtually everything would be paid for. Reimbursernent was retrospective, fee-for-service and generous, essentially a cost-plus system in which insurers only rarely challenged medical decisions. That system is now gone. Uncontrolled escalations in the cost of health care have prompted those who pay its costs—primarily governments, businesses, and insurers—to initiate a broad array of cost controls in hopes of at least restraining the rise of their expenditures, even if not actually reducing them. Among the most prominent cost-containment mechanisms is utilization review (UR).

Insurers have always engaged in retrospective review, denying payment for services that are not medically necessary, or not covered by the patient's policy, or not documented in the patient's records. Recently, however, payers have added prospective review, in which physician and patient must secure advance payer approval for certain interventions if they wish to ensure reimbursement.

Type
Article
Information
Law, Medicine and Healthcare , Volume 20 , Issue 1-2 , Spring Summer 1992 , pp. 40 - 56
Copyright
Copyright © American Society of Law, Medicine and Ethics 1992

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