Utilization Review:

Information on External Review Organizations

HRD-93-22FS: Published: Nov 24, 1992. Publicly Released: Jan 6, 1993.

Additional Materials:


Office of Public Affairs
(202) 512-4800

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.

Oct 15, 2018

Oct 1, 2018

Sep 28, 2018

Sep 17, 2018

Sep 13, 2018

Sep 10, 2018

Sep 6, 2018

Sep 5, 2018

Sep 4, 2018

Aug 24, 2018

Looking for more? Browse all our products here