Insurance & cost
Insurance utilization review: Why your days are being cut
Utilization review (UR) is the process where your insurance company periodically reviews whether continued treatment at the current level is medically necessary. It often results in authorization for fewer days than clinically recommended.
How it works
The treatment facility submits clinical updates to the insurance company every 3-7 days. A UR reviewer evaluates whether continued treatment meets medical necessity criteria. Authorization is granted for additional days or denied, requesting step-down to a lower level.
Why days get cut
Insurance uses standardized criteria that may not match individual clinical needs. Reviewers may not have addiction-specific training. Financial incentives to minimize authorized days. Criteria may not account for fentanyl-era complexity.
Your rights
Right to appeal any reduction in authorized days. Right to peer-to-peer review (your doctor speaks with the insurance reviewer). Right to continue treatment during the appeal process (for in-network facilities). Right to external review if internal appeals fail.
What the facility should do
Your treatment team should fight for appropriate authorization. If they do not advocate for continued stay, that is a red flag about the facility's commitment to clinical care over business considerations.
Frequently asked questions
What is utilization review?
Why is insurance cutting my treatment short?
Can I stay in treatment if insurance stops paying?
Disclaimer: Informational only. Not medical advice. SAMHSA: 1-800-662-4357.