Utilization Review Programs

All managed care organizations employ utilization review or management programs. Insurers spin these programs as efforts designed to ensure quality of care, but in fact these program are used to ration and limit care. For profit insurers are designed to maximize premiums and minimize benefits. Utilization review is a prime example of how benefits are minimized. These programs identify expensive treatments and deny coverage if at possible.

Utilization review programs permit insurers to interfere in the doctor-patient relationship. Through these programs, insurance companies attempt to dictate the medical judgment of physicians. The result is often inadequate or uncompensated care.

TGF works to assist providers in these processes to ensure adequacy of care, independence of physicians’ medical judgment, and appropriate reimbursement for appropriate care. TGF firmly believes that providers—rather than insurers—should determine what care is appropriate, and we fight passionately to achieve this result. We can assist in enforcing providers’ and patients’ rights in several ways, including appealing adverse decisions under existing policies or advocating for changes in medical policies.


  • All insurers have utilization review or utilization management programs, which they spin as programs designed to insure quality of care, but in fact such programs are nothing more than rationing and limiting of care
  • Insurers step between patients and physicians and seek to dictate the provision of medical care
  • TGF can assist in enforcing providers’ rights during these programs in several ways, including advocating for changes in medical policies or appealing adverse decisions within existing policies
  • TGF firmly believes that providers—rather than insurers—should determine what care is appropriate and we fight passionately to achieve this result