Medicine has long placed emphasis on the quality as well as the quantity aspects of care. Forthcoming revised Medicare utilization review regulations, carefully weighing the experiences of the first five years of the Medicare program, will reflect this emphasis.
The concept of evaluating the appropriateness of care received by the patient is far from new. Various methods, both formal and informal, have been used by the medical profession for decades. But the advent of Medicare, with its utilization review requirements, has created a focus on efficient use of resources as well as on the medical necessity of professional services furnished.
Unfortunately, one aspect of the utilization review requirements has proved confusing to both Medicare institutions and their staffs. This is the requirement for "sample review," a title that is inaccurate and confusing. This communication introduces a more descriptive title, "medical care evaluation study," to replace it and describes how an
Goldberg GA, Needleman J, Weinstein SL. Medical Care Evaluation Studies A Utilization Review Requirement. JAMA. 1972;220(3):383–387. doi:10.1001/jama.1972.03200030041010