Practitioner Update
May 1993
For more information: E-mail
A majority of states - currently 27 - have utilization review (UR)
statutes on the books. Most of these laws regulate all facets of
UR activities, including those performed by managed care entities
and indemnity insurance carriers. Generally speaking, UR involves
evaluation of the appropriateness and necessity of health care
services as related to reimbursement for these services.
Psychologists whose claims are paid by any entity subject to UR
legislation, and any practitioners who conduct reviews, should be
conversant with the details of the UR statute in their state. The
following provisions are important to know:
- definition of 'health care provider', and whether psychologists
are included among providers deemed qualified to conduct various
stages of review
- whether there is a 'like provider' requirement, i.e., that a
reviewer be licensed and competent to perform the same service as
the one he or she is evaluating
- confidentiality provisions pertaining to patient records, and
restrictions, if any, on conducting telephone reviews
- grievance and appeals procedures
- prohibitions against monetary incentives tied to the reviewer's
decision regarding appropriateness of health care services, length
of stay, or treatment setting
- whether entities subject to the law are required to disclose their
UR decision making criteria and provide a summary to providers and
patients
Managed care companies not required by law to do so are sometimes
reluctant to release their procedures and criteria for conducting
reviews. Even so, practitioners who are affected by these reviews
should request the information.
The Practice Directorate has developed and disseminated model UR
legislation that addresses the provisions listed above and several
additional important considerations. The directorate works with
state psychological associations to help secure appropriate UR
legislation and to amend existing statutes that fail to protect
patients' and providers' interests adequately. Copies of the model
legislation may be obtained from the Legal and Regulatory Affairs
Department's Office of Managed Care (202-336-5886).
