Question

describe basic utilization management techniques. Analyze why each of them might be used

Answer 1

UTILIZATION MANAGEMENT: According to the URAC, an accreditor of the health care organization, utilization is "the evalution of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called utilization review.

A set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case by case assessments of the appropriateness of care prior to its provision.

There are four basic utilization management techniques

1. Demand management
2. utilization review
3. case management
4. disease management

1.DEMAND MANAGEMENT: it is concerned with the planning process used to manage the demand for a patient care or healthcare services. it is concerned with keeping the patient as more appropriate and efficient as possible .demand may increases or decreases from day by day. to prevent unnecessary admissions or procedures by denying cases that donot meet criteria.

2.utization review: in this planning or adjusting levels of patient care depending on need. to prevent un expected financial risks to the patient. according to the priorities balancing internal and external responsibilities. in this process RN trained with utilization management ,um program manager or physician adviser plays important role.

3.case management: case manager in hospital look at a patient file and helps that patient decide on care options and financial matters.in this case management includes co ordinating and planning for safe discharge or transition to next level of care.

4.disease management: in this management care provided according to the patient condition. care plan changes according to the health condition of patient .it will help to prevent uncessary care to patient. to assess. plan, implement and evaluate patient care plans.

eg :if patient I icu ventilated but after recovery he is to put in c-pap . here cost and treatment will deffer .

In this process three are three types of reviews.

1. prospective review: method used used to reducing unneccesory admissions or procedures by denying cases that do not meet criteria.
2. concurrent review : in this case includes co ordinating and planning for a safe discharge or transition to the next level of care.
3. retrospective review: it will typically look at whether procedure location and timing were appropriate. it is related to payment.