What is utilization and case management?

In order to, differentiate between utilization management and case management using the seven case management standards, it is first important to define each individual component. To begin with, a key component of quality and cost effective care is Utilization Management (UM). Utilization management is a way to assure that the appropriate care is medically efficient, a suitable use of health care services, proper procedures, and is applicable with provisions aligned in the health benefits plan. Case Management engages quality services in a timely coordination of patients’ specific needs in an approach that promotes positive outcomes by means that are cost effective. Case management may be developed during a single health care setting that may then transition throughout the care continuum. The seven standards are key components that described to maximize benefits and minimize the opposition. Capability strategy is the first of the seven standard. In Case management capability strategy leadership accountability is an objective of health care organizations. This leadership role has a greater role in clinical outcomes as the under this standard as case management is intended to improve the management function of clinical care. Capability strategy changes the business climate to continue improvements that “align with the patients’ needs as well as the clinical and operational innovations,” (Wanless, 2010, p. 9). The second standard is the repeatable design, relates

Utilization Review- A mechanism used by some insurers and employers to evaluate healthcare on the basis of appropriateness, necessity, and quality.

Continued Stay Review- A type of review used to determine that each day of the hospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a patient’s hospitalization for care.

Preadmission Certification- An element of utilization review that examines the need for proposed services before admission to an institution to determine the appropriateness of the setting, procedures, treatments and length of stay. 

Admission Certification- A form of utilization review in which an assessment is made of the medical necessity of a patient’s admission to a hospital or other inpatient facility. Admission certification ensures that patients requiring a hospital-based level of care and length of stay appropriate for the admission diagnosis are usually assigned and certified and payment for the services are approved. 

Concurrent Review- A method of reviewing patient care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated.
 
Retrospective Review- A form of medical records review that is conducted after the patient’s discharge to track appropriateness of care and consumption of resources.

Second Opinion- An opinion obtained from another physician regarding the necessity for a treatment that has been recommended by another physician. May be required by some health plans for certain high-costs cases, such as cardiac surgery.

Discharge Planning- The process of assessing the patient’s needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting including appropriate use of resources necessary for ongoing care. 

Utilization Management vs. Utilization Review

The terms utilization review and utilization management are often used interchangeably. It is true that the evaluation process for utilization review and utilization management is similar or the same and both assess medical care for appropriateness. It is also true that the goal for both is to control the cost of healthcare services. The difference is that utilization management is a prospective process that occurs before and during the admission, procedure or treatment, while utilization review is retrospective. 

The Utilization Management Process

1. Verify eligibility- Check that the patient is covered under the health plan, and that this coverage is primary. Example:  The patient may have Medicare and insurance through his employer. The primary insurance is the one the preauthorization request would go through.
2. Verify that the requested service is a covered benefit under the insurance contract. If it is a covered benefit, determine if it requires preauthorization. Example:  Bariatric surgery may be a contract exclusion. If it is a covered benefit, it may require preauthourzation. 
3. Gather clinical information needed to determine if criteria is met for this service.
4. Review of clinical information to determine if it meets criteria for medical necessity, and level of care.
5. If guidelines are met, the requesting provider is notified of the approval.
6. If guidelines are not met, it is sent to physician review. The physician will approve or deny based on his or her medical judgement and the requesting provider will be notified of the approval, or the denial and appeal process.
7. The patient or treating physician may appeal.
8. The medical director collects more information and reviews the case again. He may also speak with the treating physician or send the information to an independent third party physician with expertise in the specialty area of the request. 

   What is utilization management?

   Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called “utilization review.”

   What is the purpose of utilization?

   Utilization is the action of using something, i.e., making practical and effective use of it. Put simply; the term refers to the use of something or the process of using it effectively.

   What is the difference between UR and UM?

   While utilization review identifies and addresses service metrics that lie outside the defined scope, while utilization management ensures healthcare systems continuously improve and deliver appropriate levels of care. Reducing the risk of cases that need review for inappropriate or unnecessary care.

   Why is it important to manage utilization?

   Utilization management can prevent unnecessary costs. Utilization management can help reduce the rising rates of healthcare costs—and in the current situation, that's more important than ever. Healthcare costs typically rise each year.