A recent opinion from the Commonwealth Court of Pennsylvania has changed the rules for Utilization Review and thrown open the doors to a new class of litigants. In Keystone Rx, LLC v. AmeriHealth (Fee ...

The utilization review process is designed to help hospitals determine the appropriate level of care and care setting for patients based on medical necessity. While this process is an expense for ...

Fact checked by Elaine Hinzey, RDKey TakeawaysUtilization review ensures medical care is used correctly and ...

Concurrent review is a utilization review process that occurs while a patient is actively receiving treatment, such as during a hospital stay. It evaluates the medical necessity and appropriateness of ...

As most workers' compensation practitioners are aware, the utilization review process was one of the main aspects of the medical cost containment provisions of the 1993 amendments to the Workers' ...

The administrative burden of utilization review processes like prior authorizations and concurrent review has long been a thorn in the side of healthcare providers. While prior authorizations have ...

The utilization review process, in which an employer may challenge the reasonableness or necessity of the medical treatment of an injured employee, was at issue in County of Allegheny (John J. Kane ...

On January 25, 2022, the U.S. Court of Appeals for the Second Circuit affirmed a lower court ruling that the Secretary of HHS violated the due process rights of Medicare beneficiaries by failing to ...

On November 10, 2025, the California Court of Appeal, Second Appellate District, Division Three, issued its decision in ...

The aggravating prior authorization process includes one step that merits scrutiny and potentially regulatory action: the peer-to-peer review.