HSM 420 Utilization Management

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HSM 420 Utilization Management
What are the primary categories of utilization management (UM)? How does UM determine medical…

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HSM 420 Utilization Management

HSM 420 Utilization Management

Course Discussions Week 3 All Students Posts – 33 Pages

What are the primary categories of utilization management (UM)? How does UM determine medical necessity through the use of evidence-based guidelines?  What do the categories used in utilization management mean in laymen’s terms?

If physicians are in charge of the care of the patient, why should they not be in charge of which services and how often the services should be rendered?  How does this apply to what is taking place in healthcare today? How has the Affordable Care Act impacted utilization management?  What is your analysis of the information that you provided?  Who is responsible for ensuring that all providers are following the medical guidelines as they deliver care?  Can a provider appeal a denial for services deemed as unnecessary if he/she feels that the service is needed?  If so, how long is the process?  If not, what are the providers options?  Is utilization management used in indemnity healthcare plans?  Is medical necessity a priority with indemnity plans?  What is the role of the provider?  If they deem that a service is medically necessary but it does not meet the UM standards will the service be covered?

According to the Institute of Medicine Committee, utilization management is a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.

In my research of utilization management, the terms management & review were used interchangeably.  So, I am a little confused about the term since management & review have different meanings.  According to our text, the categories used in utilization management were prospective, concurrent, retrospective, pended (for review), denial (no authorization), and sub authorization…