title: Evaluation of a focused dental utilization review system.
abstract: It has been suggested that the efficiency of claim-based utilization review systems could be improved by focusing on providers with very high utilization rates. This strategy assumes that 1) high utilizers are more likely to be overutilizers, 2) labeling claims (e.g., "high utilizer") do not bias the review, and 3) the claim review process is sufficiently reliable. These issues were studied in prospective dental utilization review system where dentists submit claims and radiographs to an insurance carrier so that they may obtain treatment authorization. A sample of dentists with very high and moderate utilization rates for amalgams, crowns, and bridges were identified and their pretreatment claims containing these services (N = 553) were collected. Half the services from high and moderate utilizer practices were labeled "high utilizer," and the other half were unlabeled. Seven dental consultants from two large insurance carriers independently assessed the appropriateness of the services (approve or deny) from radiographs. The results indicate that services submitted by dentists with high utilization rates were no more likely to be denied than those with moderate rates, labeling claims did not appear to bias the reviewers, and interconsultant agreement levels for denials seldom exceeded 50 per cent. The study suggests that further development of focused review systems requires a better understanding of the association between utilization rates and overutilization and new methods for improving the reliability of reviewers.
mesh_terms: D005069:Evaluation Studies as Topic; D006801:Humans; D007341:Insurance; D007344:Insurance Claim Reporting; D007347:Insurance, Dental / Q000706:statistics & numerical data*; D014481:United States; D014600:Utilization Review / Q000379:methods*