HSM420 Course Discussions Week 3


HSM420 Course Discussions Week 3
If physicians are in charge of the care of the patient, why should they not be in charge of …


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HSM420 Course Discussions Week 3

HSM420 Course Discussions Week 3

All Students Posts – 67 Pages

Utilization Management – 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…

Case Management Versus Disease Management – 34 Pages

What are the key differences between conventional case management and disease management? Provide some examples of diseases that seem to benefit from a disease management model of care.  What is case management?  What is disease management?  How would case management differ in an urban patient with kidney issues and a rural patient with kidney issues?

What happens if the patient needs to deviate from the standard?  Will the services be covered?  Since the inception of the Affordable Care Act, have the standard services that are covered by insurance companies changed?  Has the Affordable Care Act changed the way that cases are serviced?  Has it changed the way that diseases are managed?  Which states or areas use this form of integrated health care services?  Although, payers cannot deny coverage to those with pre-existing conditions, are insurance companies allowed to charge more for pre-existing conditions?  Do most disease management plans become case management plans?  What do I mean by this?  Which is more costly, disease management or case management? What are the similarities of case management and disease management?

Case management targets high-risk patients–those who, because of diverse combinations of health, social and functional problems, are likely to need hospitalization. The cost for this type of patient is high and the goal is to coordinate cares to improve continuity and quality of care as well as lower the cost of treatment.  Case management is a collaborative process that assesses plans, implements, coordinates, monitors and evaluates the options to meet the needs of the patient.

Disease management targets patients who have one major diagnosis and who, because of their major diagnosis, have a relatively standard set of needs. It encompasses all settings of care and places emphasis on prevention and maintenance.  It is more focused on the set of diseases…

HSM420 Course Discussions Week 3