The Utilization Review Process In Health Care

Case managers also provide support and information to patients and their families. Next, is utilization review. `Its main objective is to review each case and determine the most appropriate level of services, the most appropriate settings in which the services be delivered, the most cost efficient methods for care delivery and the need for planning of subsequent care. Other methods used for utilization and control are choice restriction and practice profiling' (Douglas, 2003, p.328).

Case Managers have a challenging job, often dealing with patients, community agencies and facilitating their hospital discharge to the next level of care. They collaborate and communicate with the entire healthcare team and mostly with the patient during the hospitalization process. They act as support for all stakeholders to achieve positive patient outcomes. In this paper, I will be interviewing Ian Mopas, who is a Patient Care Coordinator at Kaiser Permanente in Redwood City about his education, work training, goals, and objectives as a Care Coordinator, and his responsibilities in his organization.

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.

The Affordable Care Act was signed into law March 23, 2010 by President Barack Obama; however, the constitutionality of the law remained in question. In a controversial 5-to-4 ruling, The U.S. Supreme Court upheld the law on June 28, 2012. The ACA is thought by some as the United States health care rescue, and as its downfall by others.

The five most important characteristics for a healthcare provider is honesty, patience, empathy, responsibility, and a team player. I picked honesty because for me honesty is important because if I was the patient I would like for the nurses and doctors be completely honest with me. To be honest you have trustful. Patients should be able to always have faith in you. You always have to be honest with the patients no matter what. Honesty has a lot to do with the healthcare industry.

Over the past decade, government operated and privately owned health care organizations have made improvements identifying patient disabilities, discovering alternative treatments at the patient’s discretion, identifying the cause of diseases, and discovering lifesaving cures. The current United States health care delivery system has undergone enormous changes throughout the years. People the United States utilize health care services for many reasons: to prevent disease, to prevent future illnesses, to eliminate pain, and promote a healthier lifestyle to patients. The Patient Protection and

Health care reform in the United States is a hot topic and the source of legislation meant to make health care obtainable to Americans. Recent presidential elections have been platforms used to promote health care reform yet no one can agree on what the resolution will be. This paper will discuss ways recent health care reform measures have expanded or inhibited access to health care. This paper will discuss how changes to access may lead to influences in utilization. Concepts of what universal health care may be and how current care reflects or contrasts

Patient Accounting and Practice Management systems are designed to help health care medical practices are to improve the quality of care, cut cost, reduce risk, and increase revenues. When it comes to the size of a medical practice from small, or to a large medical practice, multi-location group this will feather the system to allow in creating and maintaining a patient billing information much faster and more efficiently then it was ever before. Medical Assistants are able to enter a patient information and post any changes much faster and more accurately with the use of a simplified medical billing software that promotes physician acceptance and much greater investment protection that provides faster insurance reimbursement and to improve

In recent years, health care has been a huge topic in public debates, legislations, and even in deciding who will become the next president. There have been many acts, legislations, and debates on what the country has to do in regards to health care. According to University of Phoenix Read Me First HCS/235 (n.d.), “How health care is financed influences access to health care, how health care is delivered, the quality of health care provided, and its cost”.

The Centers for Medicare and Medicaid Services support quality initiatives. The mission of CMS is quality health care for people with Medicare which is a high priority for the president. CMS began to start quality initiatives back in 2001 to assure quality care for all Americans through accountability. There are various quality initiatives that focus on every aspect of the health care system. From focusing on reporting quality measures for nursing homes to kidney dialysis facilities. Consumers can use the information provided on their website for these health care settings to assist them in making the right choices for the care provided.

A.1) I choose the Great Britain healthcare system from the given list to compare to the U.S healthcare system.

Meaningful use refers to a set of criteria for the EHRs are used provides must meet in order to receive incentive payments. The impact of your role as a medical assistant is to help reduce health disparities. Meaningful use sets specific objectives that eligible professionals and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services Incentive Programs. Meaningful use has 3 stages. These objectives will evolve in three stages over the next five years: 2011-2012 is Stage 1 Data capture and sharing, 2014 Stage 2 Advance clinical processes, and 2016 Stage 3 Improved outcomes.

Utilization management is described as the implementation of guidelines which reduce unnecessary use of medical resources (Kongstvedt, 2007, p.190). There are a variety of methods used to ensure costs are kept at a minimum without compromising patient care. The use of utilization management (UM) are yielding financial benefits resulting in managed care organizations (MCOs) and facilities investing more into UM programs.

As the industry continues to move away from some of the Medicare programs that were created during the Obama presidency,  the Centers for Medicare & Medicaid Services (CMS) is also pulling away from specific value-based initiatives, such as mandatory bundled payments. The CMS officially canceled two of the models that were included in the Bundled Payments for Care Improvement (BPCI) Initiative.

It was in 1977 that the United Healthcare United Health group was founded by Richard Burke. The headquarters of the company are in Minnetonka, Minnesota. This organization works towards the betterment of people's health, it help them in living a healthy life by providing them with the kind of health care that would be best for them. The main focus of United Healthcare which is a major division of the United Health group is to provide the people with better health benefits and coverage.