Physician Utilization Review: The Chasm of Potential Liability for Both Treating and Utilization Review Physicians

Abstract

There has been a dramatic escalation in the use of utilization review programs in an effort to constrain the surge of rising healthcare costs. Utilization review serves to verify the “medical necessity” of hospital admissions and specific medical procedures. However, by intruding into the traditional physician–patient relationship, utilization review programs raise an army of liability issues. Both treating physicians and utilization review physicians would be prudent to have an in-depth awareness of the risks associated with clinical and utilization review decisions and the action taken in the medical and surgical care of the patient. The two questions posed are: What is the risk of the treating physician when adverse outcomes occur when adhering to the utilization review’s advice?; and What is the risk of the utilization review physician when adverse outcomes occur in light of a treating physician following the advice of the utilization review physician?