Utilization Management and Case Management Essentials

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Utilization Management and Case Management Essentials

Introduction

The healthcare industry is undergoing radical transformations, with rising costs, concerns about the quality of service, and growth in the prevalence of chronic diseases in modern society. To address the healthcare industrys emphasized difficulties, utilization review is the process used to fit the patients clinical picture as well as the intervention strategies to evidence-based criteria (Desai et al, 2017). A healthcare professional can use this criterion to help them choose the best place to provide care for their patients at every stage of the continuum of care.

Types of Utilization Review

Retrospective, concurrent, and retrospective reviews all fall under the scope of the utilization review (Desai et al, 2017). In a retrospective review, the appropriateness of techniques, environment, and timing are evaluated after the services have been delivered. Assessment of healthcare needs before the provision of services is known as a prospective review. During treatment, the quality of the provided services is evaluated concurrently.

Processes of Assessments of Utilization Review

There are several steps involved in doing a prospective review as follows. Patients medical records, such as their Hierarchical Condition Category history and their hospital records, are evaluated by reviewers who are certified risk coders. The reviewers identify patients with HCC diseases whose diagnosis is incorrectly recorded when they study medical records. Preparation of the physician for future appointments to deal with the problem (El-Othmani et al., 2019). There must be proper documentation and inclusion of the conditions observed in the encounter with the physician. Working with pre-visit planning personnel makes the process run more smoothly and relieves the physician of some of their responsibilities.

The following are the steps involved in the concurrent review. Coordinating the patients treatment in a situation where numerous medical providers are involved. Discharge planning is the process of identifying the milestones that must be met before a patient may be allowed to leave the hospital and return home. When a patient transitions from one level of care to another, the term care transition is used.

Retrospective evaluation is comprised of several steps. Real-time chart review reveals problems with clinical documentation. Correct HCC coding information is sent to the payer by flagging the charts.

Role of Healthcare Manager in Utilization

Collaboration

Patients and their families can participate in case management meetings and other forms of interdepartmental collaboration made possible by healthcare managers. A member of this team participates in meetings related to utilization management and discharge planning.

Training

As federal and state healthcare rules change, the healthcare manager arranges staff training and notifies staff members of these changes.

Communication

The medical team, patient, and family members are kept up to date.

Quality of care maintenance

Using quality indicators and identifying areas for improvement, the healthcare manager makes sure that high-quality care is maintained or even improved upon (El-Othmani et al., 2019).

Process of prospective

Radison visited the ER with stomach pain. Radison took X-rays and other tests to diagnose appendicitis. Radison contacted his companys UMG. Radion recommends a surgical operation, therefore the organization calls the surgeon to decide if an outpatient or inpatient surgery is needed. The reviewer considers if the patient lives nearby and can have preoperative testing as an outpatient. Admission five days before surgery is often recommended. The organizations compliance with the reviewer and surgical staffs criteria maintained quality. How to best use the existing resources was decided as quickly as possible. The reviewers advice for a five-day preadmission and the growing expenses for each extra day of admission shows that healthcare costs were out of control.

Process of Concurrent

When a patient experiences cardiac symptoms, hospitals alert the appropriate utilization management organization. Discharge and stay times are given. The group calls the hospital every third day to assess if the patient needs further care. Calls will continue till the patient can return home. The patient is worried that he will not be reimbursed for his hospital stay due to non-certification judgments (Parast et al., 2019). According to the review, the hospital stay till the condition improved met quality standards. Because of utilization management organization decisions, care costs were kept in check.

Process of Retrospective

Simons daughter was close to being freed from the hospital, but she needed a ventilator to breathe. The familys case manager and doctor discuss home care. The case manager works with the parent and physician to develop a plan for transfer to the house, which includes assessing the homes wiring, providing two shifts of home nursing care daily, and purchasing medical equipment and supplies. This leads to an expense that isnt ordinarily covered by the benefit plan, but the employer and insurance make an exception, making the arrangement cheaper. In the scenario, quality of treatment is maintained because the patient is discharged on time and there are follow-up activities to check his progress. Employer insurance paid the expense of care not covered under the benefit plan.

Functions of communicating between all stakeholders involved in the Utilization

Communication with stakeholders can help ensure the timely dissemination of information for decision-making purposes by maintaining continuous contact with each stakeholder (Parast et al., 2019). Stakeholders benefit from regular updates on the success or failure of the various initiatives, which helps to manage expectations and generate support.

Stakeholders

Using usage management, insurance companies can keep a lid on their claim expenses by charging a premium that includes the administrative costs associated with the service. It is the responsibility of organizations and cares coordinators to build and manage an explicit network of providers to do so. Providers of health care take on important initiatives.

Conclusion

Meetings are the primary means of decision-making and information exchange among the various parties involved in utilization management. In this circumstance, all choices are authorized by a simple majority vote. If the requisite quorum for voting purposes is not met by the usage management committee due to a conflict of interest, additional members shall be appointed as necessary.

References

Desai, S., Gruber, P. F., Eiting, E., Seabury, S. A., Mack, W. J., Voyageur, C., Vasquez, V., Kim, H. T., & Terp, S. (2017). The Effect of Utilization Review on Emergency Department Operations. Annals of Emergency Medicine, 70(5), 623-631.

El-Othmani, M. M., Sayeed, Z., Ramsey, J. A., Abaab, L., Little, B. E., & Saleh, K. J. (2019). The joint utilization management programimplementation of a bundle payment model and comparison between year 1 and 2 results. The Journal of Arthroplasty, 34(11), 2532-2537.

Parast, M. M., & Golmohammadi, D. (2019). Quality management in healthcare organizations: empirical evidence from the baldrige data. International Journal of Production Economics, 216, 133-144.

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