Question

Today's Topic: Utilization Practices of Health Insurance Companies

What UM practices does your health insurance company follow to control costs and ensure provision of medically necessary services? This information may be available in your insurance benefits booklet or on your health plan’s website. If you do not have health insurance, go to the website of any major health insurance company and list the practices this company follows to control costs and to ensure the provision of medically necessary services.  

When posting your initial post discussion three examples found and how these examples would control costs or ensure provision of medically necessary services.

Answer 1

UM ( utilization management) purchase healthcare benefits to control the health care costs by decision- making through step by step assessment with appropriate care with the help of insurance company..It have the purpose of improving quality service and ensure efficient expenditure of money..

Three examples to control the costs for medical services.

Prospective review:

This is the review authorization performed before care is provided to avoid unnecessary service and cost payment.. pre-approval will be submitted to the insurance company review the organization information then the care providers notify with the decision..

Concurrent review:

This is the authorization performed during the admission and treatment course or episode of care..it determined by the discharged plan.this plan can include rehabilitation, hospice, or Nursing facilities..If the discharge plan got changed due to any reason in early for hospitalization keep health insurance costs less..

Retrospective review:

This is the services review the procedure,setting and payment and claims..it is the review of medical codes,the insurance company will approve the coverage the Patient already received..The insurance company look the medical records for any low cost care then it will compare the records with same other records..if with out approval treatment done unresponsive and precertification may not be done.. emergency surgery also be included in this review..most of the hospital involved in this process by providing medical documentation that involve in this treatment..