Utilization management is the evaluation of the appropriateness, medical need and efficiency of
health careservices procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefitsplan. Typically it includes new activities or decisions based upon the analysis of a case.
Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and
peer reviews, as well as appeals introduced by the provider, payer or patient.
As pre-certification and concurrent review of cases grew, utilization management spun out of
While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is forward looking and intends to manage health care cases efficiently and cost effectively before and during health care administration.
Utilization reviewis more backward looking considering whether health care was appropriately applied after it was administered.
there are four basic techniques in Utilization Management:1. Demand Management2. Utilization Review3. Case Management4. Dieseace Management
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