Utilization management (UM) is "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."
UM considers the appropriateness and medical necessity of health care services, procedures, and facilities according to evidence-based criteria or guidelines. Typically, UM addresses new clinical activities or inpatient admissions based on case analysis, but may relate to the ongoing provision of care, especially in an inpatient setting.
A UM program includes:
- Proactive procedures such as discharge planning, concurrent planning, pre-certification and clinical case appeals
- Concurrent clinical reviews, peer reviews as well as appeals introduced by the provider, payer or patient
- Roles such as UM Reviewers (often an RN with UM training), a UM program manager, and a physician adviser
- Policies regarding the frequency of reviews, priorities and balance of internal and external responsibilities
- Escalation processes for when a clinician and the UM reviewer are unable to resolve a case
- Dispute resolution for patients, caregivers or patient advocates to challenge a point of care decision
- Evaluating rater reliability among UM reviewers.
UM criteria may be developed in-house, acquired from a UM vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria and the Milliman Care Guidelines (Milliman is now known as MCG).
Video Utilization management
Review
Similar to the Donabedian healthcare quality assurance model, UM may be done prospectively, retrospectively, or concurrently.
Prospective
A prospective review is typically used to reduce medically unnecessary admissions or procedures by denying cases that do not meet criteria or allocating them to more appropriate care settings before the act.
Concurrent
Concurrent review is carried out as part of service provision and supports point of care decisions. The focus of concurrent UM tends to be on reducing denials and placing the patient at a medically appropriate point of care. Concurrent review may include a case-management function that includes coordinating and planning for a safe discharge or transition to the next level of care.
Retrospective
A retrospective review considers whether appropriate care was applied after it was administered. The retrospective review typically looks at whether the procedure, location and timing were appropriate according to the criteria. This form of review typically relates to payment or reimbursement according to a medical plan or medical insurance provision. Denial of the claim could relate to payment to the provider or reimbursement to the plan member.
Alternatively, a retrospective review may reflect a decision about the ongoing point of care. This may entail justification according to the UM criteria. The review may recommend keeping a patient at the same point of care or shifting the patient to a higher or lower point of care to match the UM criteria. For example, an inpatient case situated in a telemetry bed (high cost) may be evaluated on a subsequent day of stay as no longer meeting the criteria for that bed. This may be due to changes in acuity, patient response or diagnosis, or may be due to UM criteria that may change for each continued day of stay. At this time the reviewer may propose alternatives such as a test to determine the future level of care.
Maps Utilization management
Criticism
UM has been criticized for treating the cost of care as an outcome metric. This confuses the objectives of healthcare and potentially reduces healthcare value by mixing up processes with results.
Some authors have pointed out that when cost-cutting is the focus of UM criteria, UM may lead to overzealous prospective denial of care as well as retrospective denial of payment. The result may be care delays or unexpected financial ramifications to patients.
See also
- Case management (US health system)
- Health insurance
- Managed care
References
Source of article : Wikipedia
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