Utilization Management in Healthcare/MHM505.Mod3.Case

Running head : UILIZATION MANAGEMENT

Utilization Management in Healthcare

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Introduction

Utilization review (UR ) is the part of utilization management used by managed care industry . It has a task to monitor the use of resources in healthcare , to determine the need of the requested medical care Concurrent UR is the strategy used to determine need of resources in particular in hospital setting (Murray , 2001 . During the review the patient information is shared with payer , who further determines if the particular care is medically necessary corresponding to the terms in

the contract between the provider and the payer . Costs of the care that meets the criteria are certified for the reimbursement . Every American patient , covered by health insurance is exposed to UR . The widespread application of the process made utilization management a significant industry (Murray , 2001 . Currently the usefulness and effectiveness of UR process is widely discussed

Hereunder the strength and weaknesses of UR from hospital care perspective are presented

UR as part of the Utilization management process

Utilization review (UR ) is the process enabling to determine the need of the medical care requested . Three types of UR are defined (1 perspective - the rational of the request is determined before the treatment (2 ) concurrent - the need is evaluated and approved during the treatment and (3 ) retrospective - the review of the entire treatment process is taking place after the treatment (cited Corcoran VanDiver 1996 . The main aim and strength of the concurrent UR is to ensure that the patient gets right care...