Summary: Utilization review organizations (URO) significantly influence the provision of and payment for health care in this country. Because recommendations made by these organizations can impact the care approved for payment, a URO might affect a patient's access to health care. As a result, there is considerable interest in the health care community about who makes utilization decisions, their professional experience, and the review criteria they use. This fact sheet provides information on (1) the size and ownership of UROs, (2) the professional qualifications of the staff involved in utilization review decisions, (3) the complexity of decisions made by various types of staff, (4) appeal procedures, (5) clinical review criteria used by UROs, and (6) quality assurance procedures implemented to ensure adherence to company directives. In short, GAO discovered the following: that UROs often employ physicians on a part-time basis or as consultants; registered nurses are heavily involved in first-level review decisions but doctors become more involved during the second-level review and appeals process; UROs generally use commercially developed review criteria when making their recommendations; most UROs have established appeal procedures; of the few utilization decisions that are appealed, many are successful; and UROs have implemented quality assurance procedures to ensure adherence to company directives.
