Utilization Review: Information on External Review Organizations: HRD-93-22FS (Paperback) (ISBN-13: 9781289069841)

Pursuant to a congressional request, GAO reviewed utilization review organizations (URO), focusing on: (1) the size and ownership of URO; (2) the professional qualifications of staff involved in utilization review decisions; (3) the complexity of decisions made by various staff; (4) appeal procedures; (5) clinical review criteria used by URO; and (6) quality assurance procedures implemented to ensure adherence to company directives.

GAO found that: (1) physicians are usually employed by URO on a part-time basis or as consultants/advisors; (2) registered nurses are heavily involved in first-level review decisions, but physicians become more involved during the second-level review and appeal process; (3) URO generally used commercially developed review criteria when making recommendations; (4) most URO have established appeal procedures; (5) of the few utilization decisions that are appealed, many are successful; (6) URO have implemented quality assurance procedures to ensure adherence to company directives; (7) in 1990, a commission was established to develop quality assurance standards for URO and to accredit organizations that seek this distinction; (8) many URO set minimum qualifications and education levels for clinical and nonclinical staff; and (9) URO activities included prehospital admission certification review, concurrent reviews, second surgical opinions, and case management.

Author: U. S. Government Accountability Office (
ISBN-10: 1289069840
ISBN-13: 9781289069841
Publisher: Bibliogov
Language: English
Published: 06/27/2013
Pages: 104
Format: Paperback
Weight: 0.44lbs
Size: 9.69h x 7.44w x 0.22d