There is no single accepted definition.
According to URAC, an accreditor of health care organizations, utilization management is "the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called ‘utilization review'."
The Institute of Medicine (IOM) Committee on Utilization Management by Third Parties recognizes UM as "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision."
The APTA Board of Directors GUIDELINES: PEER REVIEW TRAINING (BOD G03-05-15-40) defines utilization review as "a system for reviewing the medical necessity, appropriateness, and reasonableness of services proposed or provided services to a patient or group of patients. This review is conducted on a prospective, concurrent, and/or retrospective basis to reduce the incidence of unnecessary and/or inappropriate provision of services. Utilization review is a process that has two primary purposes: to improve the quality of services (and patient outcomes) and to ensure the efficient expenditure of money."
3 Types of UM
Prospective review is conducted at the onset of a service or treatment and is also referred to as precertification or prior authorization. This review is performed before care is rendered in order to eliminate or reduce unnecessary services. Prospective review may have the impact of not authorizing or limiting care that had been recommended by the evaluating provider(s).
Concurrent reviews performed during the course of treatment or episode of care. Intervention occurs at varied intervals and may encompass case management activities such as care coordination, discharge planning, and care transitioning. Concurrent review may have the impact of curtailing an existing episode of care.
Retrospective review is conducted after the service has been completed and assesses the appropriateness of the procedure, setting, and timing in accordance with specified criteria. Such reviews often relate to payment and may result in denial of a claim. Financial risk for a retrospective denial is often borne by the provider.