These Guidelines for Utilization Review are general guidelines. They have been developed for orthopaedists, who are involved in the planning, implementation and evaluation of utilization review activities. Rationale Many organizations and entities are attempting to develop guidelines for reasonable utilization and quality review activities.
Most guidelines are broad and nonspecific.
Most guidelines excuse many current activities that might otherwise be considered inappropriate. The efforts of these groups vary and their outcomes are dependent, in most instances, on their own interests and needs. The purchaser wants accountability for value. The third party payer needs to control claims costs and hold the line on premiums. The private practitioner wants to limit cumbersome administrative factors and the administrative cost of medical practice and to be assured that review does not interfere with the ability to make wise decisions about appropriate care.