What are the similarities among utilization management, discharge planning and case management?
1. What are the similarities among utilization management, discharge planning and case management?
2. What are the differences among utilization management, discharge planning and case management?
****What Is Utilization Management in Healthcare?
Utilization management (UM) is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis.
UM is an on-going process. It occurs in 4 steps:
1. Prospective review – this is when one needs to ascetain if the procedure is necessary or an alternative is appropriate. Usually at a lower cost. An example an X-Ray rather than an MRI.
2. Concurrent – occurs as the procedures are being conducted and there is a possibility for further testing or prior activity is sufficient.
3. Discharge Stage – Addresses patient safety. Is the patient safe for discharge? Is there a need for further interventions. This step addresses the quality of care provided and is there a possibility if discharged might there be a readmission. As noted in class if a patient is readmitted for the same pre-admission there is loss of revenue from the insurance plan.
4. Retrospective Review – This stage is a review by the insurance plan who may seek further information regarding treatment during the stay. If the insurance plan seeks further information lack of substantial objective documentation may prevent full payment for the course of stay. This stage is also important to the question of “Quality Care”.
It is always important for the case manager to be certain all documentation is completed, objective, and identifies the goals and interventions planned have been achieved. Or if not achieved the documentation provides evidence of why the goal was not achieved.