Utilization management
Encyclopedia
Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care
services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the analysis of a case.
Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer review
s, as well as appeals introduced by the provider, payer or patient.
As pre-certification and concurrent review of cases grew, utilization management spun out of utilization review. While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is prospective and intends to manage health care cases efficiently and cost effectively before and during health care administration. Utilization review is more retrospective considering whether health care was appropriately applied after it was administered.
There are four basic techniques in utilization management:
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the analysis of a case.
Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer review
Peer review
Peer review is a process of self-regulation by a profession or a process of evaluation involving qualified individuals within the relevant field. Peer review methods are employed to maintain standards, improve performance and provide credibility...
s, as well as appeals introduced by the provider, payer or patient.
As pre-certification and concurrent review of cases grew, utilization management spun out of utilization review. While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is prospective and intends to manage health care cases efficiently and cost effectively before and during health care administration. Utilization review is more retrospective considering whether health care was appropriately applied after it was administered.
There are four basic techniques in utilization management:
- Demand Management
- Utilization Review
- Case Management
- Disease Management
See also
- Managed careManaged care...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
- Case management (USA health system)
- Health insuranceHealth insuranceHealth insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...