Utilization Management- Review of services to ensure that they are medically necessary, provided in the most appropriate care setting, and at or above quality standards. Utilization Review- A mechanism used by some insurers and employers to evaluate healthcare on the basis of appropriateness, necessity, and quality. Preadmission Certification- An element of utilization review that examines the need for proposed services before admission to an institution to determine the appropriateness of the setting, procedures, treatments and length of stay. Admission Certification- A form of utilization review in which an assessment is made of the medical necessity of a patient’s admission to a hospital or other inpatient facility. Admission certification ensures that patients requiring a hospital-based level of care and length of stay appropriate for the admission diagnosis are usually assigned and certified and payment for the services are approved. Concurrent Review- A method of reviewing patient care and
services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated. Second Opinion- An opinion obtained from another physician regarding the necessity for a treatment that has been recommended by another physician. May be required by some health plans for certain high-costs cases, such as cardiac surgery. Discharge Planning- The process of assessing the patient’s needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process
ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting including appropriate use of resources necessary for ongoing care. Utilization Management vs. Utilization ReviewThe terms utilization review and utilization management are often used interchangeably. It is true that the evaluation process for utilization review and utilization management is similar or the same and both assess medical care for appropriateness. It is also true that the goal for both is to control the cost of healthcare services. The difference is that utilization management is a prospective process that occurs before and during the admission, procedure or treatment, while utilization review is retrospective. The Utilization Management Process
Types of Utilization Management
What are three important functions of utilization management?Utilization Review.. Case management.. Discharge planning.. What is utilization management quizlet?Controls health care costs and the quality of health care by reviewing cases for appropriateness and medical necessity. Utilization Management (UM) Management of health services to ensure that when offered they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
What is a component of an organization's quality management infrastructure?What component of the organization's quality management (QM) activities is often documented in the QM plan? Frequency of department staff performance evaluations. Names of improvement project team members. Performance improvement model used in the organization. Procedure for reporting adverse patient events.
What is utilization quizlet?what is a utilization review? the process of assessing medical care services to assure quality, medical necessity, and appropriateness n terms of level of care and locus of treatment.
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