Utilization Review In Health Care

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.

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).

Evaluation of a patient’s outcome, to determine the effectiveness of the treatment that they received while under my care, is

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.

9. The review of systems (ROS) is documented for patient care purposes and also factors into the ________________ for the patient 's visit.

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

Utilization management has taken a key role in the health reform act because it evaluates the need, appropriateness, and the efficiency of the health care services which will be used by the covered individual. Health insurance plans are pressured to find ways to reduce plan costs and improve the quality of care provided to their members. Utilization management efforts have reduced inappropriate services and high medical costs just by taking some time to review pre-authorizations instead of providing clinically inappropriate, out-of-network services which prevents the accurate care for patient and increases cost for plans. Today’s decision-making and support of utilizations for members are performed in real-time. Real-time utilization achieves the decrease of unnecessary expenses and improves member’s health. Use of unnecessary services increases the cost for plans and limits them on the amount of services they can provide to members who are in dire need of them.

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”.

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

Meaningful Use is the improvement of the way we deliver healthcare with the use HER. Several areas of patient care can be improved including how engaged the patient’s family can be in the healthcare process, better outcomes in the clinical setting and the empowerment of the patient to see more than they could in a paper chart.

This Stage 1 started from 2011-2012, its objective dealt with data capture and sharing, these sheets are providing these services to assist professionals and hospitals understand the requirements of each objective and demonstrate meaningful use success. This stage also allows qualified providers to receive their payment after fulfilling nine core objectives and one public health objective. The second stage of the Meaningful Use is Stage 2 started in 2014; it dealt with the advanced clinical processes. This Stage introduces new aims and measures, as well as higher entries; it also required health care providers to prolong EHR capabilities to a greater portion of their patient populations. The last stage of the Meaningful Use is Stage 3, this Stage it still in a building phase. Its objective will be focusing on improving quality, safety, efficiency, and leading to improved outcomes. Even though the details of this program have not been finalized, Meaningful Use Stage 3 will work to make the program easier to understand. It will provide the professionals (EPs) and hospitals the ability to exchange and use information between electronic health records, and improve patient outcomes. Based on the current timeline, healthcare providers have the choice to begin Stage 3 Meaningful Use in 2017 but are not permitted to use it until

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.

One of the highlights of the “war on waste” policy is a strong effort to reduce the cost of health care by not performing superfluous procedures on patients. The medical center uses a computer program that applies a criteria system in ordering diagnostic tests which confirms if

The facility’s Utilization Management Program may need continued review on a periodic basis in order to keep it on par with the model Utilization Management Program as described by the HealthCare Advisory Council. In keeping with these lines, the program is updated, reviewed and approved annually by a team from the HealthCare Advisory Council itself. The different types of reviews and how they lead to improvements in the quality of care is now outlined below:

Having a single view of the patient and their treatment and recovery plan is invaluable in ascertaining which are the most and least effective tactics in treatment. The 360-degree view of the patient and the many processes supporting them is crucial for increasing the accuracy, effectiveness and performance of treatment programs over time (Blakeman, 1985). Computerized management systems are critical for organizing, analyzing and translating the massive amount of data captured on patients, treatment and recovery processes, and the use of supporting IT systems to optimize patient health and organizational provider performance (Peshek, Cubera, Gleespen, 2010). The ability to aggregate and intelligently use all available data, information, patient-based and process-generated data to deliver higher levels of quality care is possible when computerized management systems are used throughout healthcare organizations.