Healthcare utilization management involves various processes to evaluate and optimize the use of healthcare resources. These include utilization review to assess the medical necessity of treatments, pre-authorization to obtain approval for services, concurrent review during treatment, case management for complex patients, disease management for chronic conditions, quality improvement activities, and cost containment measures. The overall goal is to enhance patient outcomes while ensuring efficient and sustainable healthcare delivery through collaboration between providers, payers, and patients.

2. Healthcare
Utilization
Management
Utilization Review
Pre-authorization
Concurrent Review
Case Management
Disease Management
Quality Improvement
Cost Containment

3. Healthcare Utilization Management
1. Utilization Review: This involves evaluating the medical necessity and appropriateness of healthcare services or treatments before they are
provided or during the course of treatment. It ensures that the care being delivered is necessary and meets established medical standards.
2. Pre-authorization: Pre-authorization is the process of obtaining approval from the healthcare payer before specific medical services,
procedures, or treatments are performed. This helps prevent unnecessary or excessive utilization of healthcare services.
3. Concurrent Review: Concurrent review is conducted during the course of treatment to assess the patient's progress and the continued need
for specific medical services. It ensures that the ongoing care is appropriate and medically necessary.
4. Case Management: Case managers work closely with patients, healthcare providers, and payers to coordinate and manage the overall
healthcare services for patients with complex medical needs. They ensure that the care is well-coordinated, cost-effective, and meets the
patient's healthcare goals.
5. Disease Management: This concept involves implementing strategies and interventions to manage chronic conditions effectively, reduce
complications, and control healthcare costs.
6. Quality Improvement: HUM also focuses on continuous quality improvement in healthcare delivery. Data analysis and feedback mechanisms
are used to identify areas for improvement, enhance patient outcomes, and minimize medical errors.
7. Cost Containment: Healthcare Utilization Management aims to control healthcare costs by preventing unnecessary tests, treatments, and
hospitalizations while maintaining the quality of care.
8. Overall, Healthcare Utilization Management plays a crucial role in optimizing healthcare resources, enhancing patient outcomes, and
ensuring the sustainability of healthcare systems. It involves collaboration among healthcare providers, payers, and patients to achieve
efficient and effective healthcare delivery.

5. Healthcare
Utilization
Management

6. Healthcare Utilization Management
• การบริหารจัดการการใช ้บริการด ้านสุขภาพ
• การบริหารจัดการการใช ้บริการทางการแพทย์
• กระบวนการหรือกิจกรรมที่เกี่ยวข ้องกับการประเมิน ติดตาม และควบคุม
การใช ้บริการด ้านสุขภาพเพื่อให ้เกิดประสิทธิภาพและคุณภาพในการ
ดูแลรักษาของผู้ป่ วย
• ลดความเสี่ยงทางการเงินและความเสี่ยงทางคลินิกในระบบบริการด ้าน
สุขภาพ