Health Affairs

Posting date: June 18, 2003

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Health Affairs, 10.1377/hlthaff.w3.275
Copyright © 2003 by Project HOPE

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Managing Care: Utilization Review In Action At Two Capitated Medical Groups

Kanika Kapur ^1*, Carole Roan Gresenz ², David M. Studdert ³

¹ Kanika Kapur is an associate economist at RAND in Santa Monica, California.
² Carole Roan Gresenz is an economist at RAND in Arlington, Virginia.
³ David Studdert is an assistant professor of law and public health at the Harvard School of Public Health in Boston.

^*Corresponding author.

Abstract

Despite widespread concern about denials of coverage by managed care organizations, little empirical information exists on the profile and outcomes of utilization review decisions. This study examines the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review. We found much higher denial rates than those previously reported. Denials were particularly common for emergency care and durable medical equipment. Retrospective requests were nearly four times more likely than prospective requests were to be denied, and when prospective requests were denied, it was more likely because the service fell outside the scope of covered benefits than because it was not medically necessary.

Key Words: Access to Care, Insurance Coverage, Managed Care--Consumers, Managed Care--Quality

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