UTILIZATION MANAGEMENT

Utilization management in managed care

Utilization management in managed care

Introduction

The evaluation of medical need, appropriateness to medical health, and efficiency of healthcare activities, services and procedures under the provision of beneficial health plan is termed as Utilization management. This will include the description of the proactive procedures, proactive processes introduced by healthcare provider, or patients. The utilization management evaluates the administration procedure and monitors the appropriate delivery of healthcare to the patient.

Utilization Management is very important in healthcare industry, as it works on priority basis for ensuring the support to the patient and achieving the positive clinical outcomes. Evidence based practices will be the major part of our discussion to determine the right care. This is the most widely used cost-containment approach which contributed to limit the clinical autonomy. This reduces inappropriate and unnecessary consumption of healthcare services. This paper will be discussing the importance of utilization management in healthcare, its current status and its future application. This paper will further discuss the contribution of utilization management towards providers, MCOs and patients. In addition, the paper will further explore future role of utilization management which can be used as a guide to develop a better utilization management strategy for the future.

Discussion

The use of healthcare services through a diverse set of activities is influenced by the utilization management. This has become the most cost-contaminated approach in our sector of health care. However, the utilization management in managed care is still a controversy and it offers a lot of debate. Utilization management is strongly critic by the physicians because this process not only reduces their clinical autonomy but it also has a major impact to intolerable administrative burden in managed care. Many other third party payers and managed care plans have proposed utilization management as an imperfect process, however, they still recommend it to be necessary. Utilization management ensures that patient receives right care at right time without delay. This lower costs and improves clinical outcomes. Across the healthcare, the importance and value of health utilization management is reinforced by the cost effective care. This will be serving healthcare continuum including hospitals, health plans, mental healthcare, and long-term care. The standards addressed by the URAC's Health Utilization Management are:

Medical essential criteria promoting consumer safety;

Maintaining confidentiality in utilization management procedure by maintaining health information and electronic health records (EHR);

Peers for medical essential review;

Flexibility is the key for UM organizations and functions within healthcare benefit programs, including health maintenance organizations, indemnity insurance, consumer directed health plans, healthcare providing organizations, and third party payers.

In order to manage mental health cost, improve outcomes, and abuse treatment process; employers, managed care organizations and purchasers need driving factors such as Economic, societal, and regulatory factors. For this purpose, the Wellstone-Domenici Parity Act, became effective from January, 2010, which states that employers offering benefits to mental health cannot require higher co-pays or more restrictive treatment limits on mental health and substance abuse treatment in comparison with surgical and medical ...