Commission for Case Manager Certification (CCMC) Practice Exam

Utilization review focuses on evaluating the appropriateness and necessity of healthcare services provided to patients. It reviews past procedures and interventions to ensure that they were medically necessary and that the rights of patients were respected throughout the process. This process includes assessing whether the care provided was in line with established guidelines and protocols, as well as verifying that patients received the right level of care without unnecessary or inappropriate interventions.

By concentrating on past procedures, utilization review helps to maintain quality and accountability in healthcare systems. It aims to ensure that services rendered meet criteria for necessity, thus promoting efficient use of resources and safeguarding patient rights. It provides essential feedback for improving future care and informs healthcare providers about compliance with clinical standards and regulations.

While current patient needs and future care plans are important aspects of managing patient care, they are not the focal point of utilization review, which is primarily retrospective in nature. Securing funding for services, though also a vital function of healthcare management, is not the main objective of utilization review. The emphasis lies in reviewing past care to support accountability and quality assurance in the healthcare delivery process.