- Utilization management
Utilization management is the evaluation of the appropriateness, medical need and efficiency of
health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicablehealth benefits plan. Typically it includes new activities or decisions based upon the analysis of a case.Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and
peer review s, as well as appeals introduced by the provider, payer or patient.As pre-certification and concurrent review of cases grew, utilization management spun out of
utilization review .While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is forward looking and intends to manage health care cases efficiently and cost effectively before and during health care administration.
Utilization review is more backward looking considering whether health care was appropriately applied after it was administered.ee also
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Managed care
*Utilization review
*Case management
*Health insurance there are four basic techniques in Utilization Management:1. Demand Management2. Utilization Review3. Case Management4. Dieseace Management
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