Systematic means for reviewing and controlling patients use of health services and providers use of health care resources. A formal review of patient utilization or of the appropriateness of health care services, on a prospective, concurrent or retrospective basis. There are three basic kinds of utilization review used to confirm the appropriateness and necessity of medical care. Retrospective review is for review of services after they have been rendered. Concurrent review is for review of services while they are being rendered such as requesting an extended length of stay for inpatient services.
Prospective review is for review of services before they have been rendered.
Managed Care Organization s may use these kind of incentives to encourage certain behavior by providers, such as appropriate use of specialists and avoidance of duplication or unnecessary tests.