Utilisation Review

Utilisation review involves the systematic evaluation of healthcare services to determine medical necessity, appropriateness, and efficiency, typically for purposes of authorising payment under health insurance or workers' compensation schemes. In Australia, utilisation review functions exist within Medicare (through compliance activities and item number reviews), private health insurers (assessing whether services are covered benefits), and workers' compensation insurers (determining whether treatment is reasonably necessary and related to work injury). Healthcare providers conducting utilisation review face potential liability for denying or delaying medically necessary care, with claims alleging that payment denial prevented patients from receiving timely treatment causing harm. Professional indemnity insurance may provide limited or no coverage for utilisation review activities, as these administrative functions differ from direct clinical care. Utilisation review physicians and nurses require specific policies addressing their advisory role in claims assessment, including protection for recommendations to deny or limit treatment where made in good faith based on clinical guidelines. Key insurance considerations include whether reviewers owe a duty of care to patients (separate from treating practitioners), the standard applied in assessing clinical necessity, and whether reviewers may be vicariously liable for outcomes of denied treatment. Coverage typically requires reviewers to apply consistent evidence-based criteria and document rationale for benefit determinations.

Utilisation review involves the systematic evaluation of healthcare services to determine medical necessity, appropriateness, and efficiency, typically for purposes of authorising payment under health insurance or workers' compensation schemes. In Australia, utilisation review functions exist within Medicare (through compliance activities and item number reviews), private health insurers (assessing whether services are covered benefits), and workers' compensation insurers (determining whether treatment is reasonably necessary and related to work injury). Healthcare providers conducting utilisation review face potential liability for denying or delaying medically necessary care, with claims alleging that payment denial prevented patients from receiving timely treatment causing harm. Professional indemnity insurance may provide limited or no coverage for utilisation review activities, as these administrative functions differ from direct clinical care. Utilisation review physicians and nurses require specific policies addressing their advisory role in claims assessment, including protection for recommendations to deny or limit treatment where made in good faith based on clinical guidelines. Key insurance considerations include whether reviewers owe a duty of care to patients (separate from treating practitioners), the standard applied in assessing clinical necessity, and whether reviewers may be vicariously liable for outcomes of denied treatment. Coverage typically requires reviewers to apply consistent evidence-based criteria and document rationale for benefit determinations.