HSM420 Discussions Week 3


HSM420 Discussions Week 3
What are the primary categories of utilization management (UM)? How does UM determine…



HSM420 Discussions Week 3

HSM420 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?…

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?…