Utilization Management (UM)

Utilization Management (UM)

The three processes of utilization management (UM) include prior authorization, concurrent review, and retrospective review. Prior authorization (pre-auth) includes UM practices that occur before a clinical encounter and the initiation of interventions (Giardino & Lyn, 2021). Concurrent review occurs during the admission of a patient in health care facilities and the provision of clinical care services, while retrospective review utilization management occurs after the clinical encounter and deployment of interventions.

Prior authorization, as it occurs during the pre-deployment of interventions and patient admission to a care plan, is aimed at setting up controls to ensure that the patients receive the deserved care and that the appropriate clinical care is provided (Giardino & Lyn, 2021). Pre-auth creates a patient profile used to design efficient and effective care coordination. Pre-auth also protects patients from unnecessary care services and control of care-related costs (Gaines et al., 2020).

Concurrent review is an oversight process. It scrutinizes the type of care services provided to the patient to determine its necessity, quality, and the settings in which it is delivered (Giardino & Lyn, 2021). The concurrent review ensures that the patient receives efficient and effective care services. It allows for monitoring and improving the quality-of-care services provided and their outcomes to aid in discharge decisions (Giardino & Lyn, 2021).

A retrospective review analyzes the appropriateness and quality of care provided (Giardino & Lyn, 2021). It relates the medical bill to the efficiency and effectiveness of the care provided. It combines information from pre-auth and the concurrent review processes to determine the compliance of the care services with set standards of care and quality outcomes measures to related care services to costs.

The concurrent review process is the most important in UM. The concurrent review level of the UM is where care services are delivered, and it also allows for quality monitoring of delivered care and its effectiveness in the case. The process can assist in developing additional information that is beneficial to case and disease management.

References

Gaines, M. E., Auleta, A. D., & Berwick, D. M. (2020). Changing the Game of Prior Authorization: The Patient Perspective. JAMA, 323(8), 705–706. https://doi.org/10.1001/JAMA.2020.0070

Giardino, A. P., & Lyn, M. A. (2021). Utilization Management, Case Management, and Care Coordination. Medical Quality Management, 139–175. https://doi.org/10.1007/978-3-030-48080-6_7

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The principal objective of utilization management is the reduction of practice variations by establishing parameters for the cost-effective use of healthcare resources. There are four (4) main techniques or tools used in utilization management: demand management, utilization review, case management, and disease management. For the Week 3 discussion, address the following, keeping in mind the above information:

Utilization Management (UM)

Differentiate between the three (3) main processes of institutional utilization management.
Determine the main purposes of each process of institutional utilization management. Which process do you think is the most important, and why?
To support your work, refer to the readings and relevant outside research. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Your initial posting should be addressed at 150-300 words. Submit your document to this Discussion Area by the due date assigned. Be sure to cite your sources using APA format.

Respond to your peers throughout the unit. Justify your answers with examples, research, and reasoning. Follow-up posts need to be submitted by the end of the week.