Utilization management refers to utilization of techniques that grant purchasers to handle the cost of health care privileges by evaluating patient care effectiveness before its provision with the use of evidence-based guidelines. Utilization management covers activities a payer uses to subdue overall medical costs (Kongstvedt, 2013). Utilization management can either be through a managed care organization or a health maintenance organization. The technique evaluates the medical need for health care services, protocols, and contrivances comparing them to the facts-based criteria and that which pertains an excellent health insurance plan. It discourses new clinical operations, inpatient concession or ongoing care based on the assessment of a case. Some of the utilization management protocols include clinical case appeals, discharge, and simultaneous planning and finally pre-certification. It envelops future processes such as synchronous peer and clinical reviews. A complete set of utilization management in managed health care includes standards, roles, procedures, and policies.
Distribution of these roles for useful application of utilization management requires the involvement of reviewers who are qualified nurses, program manager, and physician adviser. The policies may include neutrality of internal and external obligations, periodic reviews and top agendas. Procedures during utilization management, for instance, solving disputes to concede patients to discuss care decisions and challenge inter-rater effectiveness amongst the reviewers. The application of utilization management reviews may be made simultaneously, prospectively and retrospectively. Prospectively, to subdue healing superfluous processes or admissions by refuting cases that won't meet criteria. Concurrently to enhance case management by conducting and planning for discharges or transitions to next care levels. Retrospectively, scrutinizes protocols, location, and occurrence thus ongoing care payments for medical insurance and plan.
Delegate your assignment to our experts and they will do the rest.
Utilization management plays significant roles in health managed care as it is a strategy used by or on behalf of payers to manage resources. Integration of this technique ensures risk management, intelligent use of health care resources like secure smooth referrals and proper care. It curbs denials and enables requests for appeals as well. The purpose of utilization management enhances the detection of improper compensations for coded services, duplicate, and non-covered services. Reviews are also enabled to recover erroneous reimbursement to check the effectiveness of utilization management. It facilitates documentation, automated reminders, patient monitoring, and involvement, supportive decision making and proper communication between patents and health facilitators.
Another crucial role of this strategy it thwarts health care facilities from retroactive claims compelling the surrender of already received cash. Generally, this type of management in health care facilities allows cost-effective care. It is paramount to note that the rate at which economic, technological, social or even competitive adjustments affect health care prompt for utilization management. Thus, it enables health care facilities to create successful strategies to ensure the evolution of the health care environment. The future of health care is envisioned with this as health care facilities are provisioned with structured thinking of transforming goals to reality (Ginter, Duncan & Swayne, 2018) . Therefore, a health care management system should employ utilization management to ensure the provision of benefit coordinative health care services, control costs and secure the future using this strategy.
However, utilization management faces several setbacks as well. For instance, the trained nurses for utilization management, the reviewers, compromise confidentiality through the muddle of financial and medical reports. Unconventional reviews as such these may disrupt ongoing treatment procedures that primarily might cause physical harm to crucial patients like those of psychiatric cases. Recent utilization management programs are very manual, pricey and inefficacious. Most health care facilities have several authorization lists to suit various lines of business and patrons incurring costs on administrative software and training of personnel. According to previous studies, up to 64% of medical staff find it hard to distinguish which services need prior authorization.
Health care payers report key losses in utilization management especially in exchange markets with multiple planning to withdraw entirely from these services. Health care facilities will presumably encounter similar fate of vanishing from a sprouting market in case they do not evolve utilization management to befit consumer market. There are different health characteristics. Hence, the strategy should ensure that it achieves cost-effectiveness and streamline the usage of resources in the dynamic exchange of health care services (Christian & Fleming, 2016). Utilization protocols are in a manner that thwarts or scare patients from seeking or proceeding with conventional medical services. Thus, the health care organizations end up facing losses due to this inhibiting factor. There is a lack of a proper mechanism to feedback; contact managed care organizations regarding utilization management organizations. Consequently, this refutes criticism that should help these health care organizations develop user-friendly protocols that may resolve disputes that unravel.
Services rendered behind utilization management should focus on transparency and central focus on patient needs and demands by health care organizations. Therefore, health systems should aim at reinventing proper care, which is cost-effective and within the right setting. Enabling effective communication between utilization management providers and patients should be after the care judgment. The use of a proper system for instance the pre-authorization model, that swaps the neutrality of interactions from post-care to pre-care decisions. Hence, this approach soars the value of reviews and foster communicative collaboration between service providers and buyers ensuring quality care around evidence-based alternatives.
References
Christian, B., & Fleming, N. (2016). Risk Based. Data Driven. The New Face of Utilization Management. Retrieved from: https://www.accenture.com/t20160627T003921__w__/us-en/_acnmedia/PDF-23/Accenture-Utilization-Management-Risk-Based-Data-Driven-V1.pdf
Ginter, P., Duncan, W., & Swayne, L. (2018). Strategic management of health care organizations (8th Ed.). New Jersey: John Wiley & Sons Inc.
Kongstvedt, P. (2013). Essentials of managed health care, sixth edition . Burlington, Mass.: Jones & Bartlett Learning.
