Utilization management is the evaluation of health care services, procedures, and facilities to determine their medical necessity, appropriateness, and efficiency according to established guidelines and health plan provisions. It aims to ensure effective and efficient use of health care resources and delivery of high quality, medically necessary care. Utilization management techniques include prospective review, concurrent review, retrospective review, and pre-certification of services. It utilizes clinical guidelines like McKesson's InterQual Criteria and Milliman Care Guidelines to standardize decision making. The goals of utilization management are to improve health outcomes, reduce over- and under-utilization of services, and lower health care costs.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
Credentialing refers to the process of collection and verification of the evidences of credentials of a doctor who is to be given the responsibility of
treating patients in the hospital. The process
ensures the authenticity of the details provided
by the healthcare practitioner or doctor.
March 02, 2018
Value-based health care is one of the most pressing topics in health care finance and policy today. Value-based payment structures are widely touted as critical to controlling runaway health care costs, but are often difficult for health care entities to incorporate into their existing infrastructures. Because value-based health care initiatives have bipartisan support, it is likely that these programs will continue to play a major role in both the public and private health insurance systems. As such, there is a pressing need to evaluate the implementation of these initiatives thus far and to discuss the direction that American health care financing will take in the coming years.
To explore this important issue, the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School collaborated with Ropes & Gray LLP to host a one-day conference on value-based health care. This event brought together scholars, health law practitioners, and health care entities to evaluate the impact of value-based health care on the American health care system.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/will-value-based-care-save-the-health-care-system
Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services.
These are in contrast to ad hoc committees, department and unit committees.
Financial Management In Healthcare PowerPoint Presentation SlidesSlideTeam
Presenting this set of slides with name - Financial Management In Healthcare Powerpoint Presentation Slides. This PPT deck displays fourty slides with in depth research. Our topic oriented Financial Management In Healthcare Powerpoint Presentation Slides presentation deck is a helpful tool to plan, prepare, document and analyse the topic with a clear approach. We provide a ready to use deck with all sorts of relevant topics subtopics templates, charts and graphs, overviews, analysis templates. Outline all the important aspects without any hassle. It showcases of all kind of editable templates infographs for an inclusive and comprehensive Financial Management In Healthcare Powerpoint Presentation Slides presentation. Professionals, managers, individual and team involved in any company organization from any field can use them as per requirement.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
March 02, 2018
Value-based health care is one of the most pressing topics in health care finance and policy today. Value-based payment structures are widely touted as critical to controlling runaway health care costs, but are often difficult for health care entities to incorporate into their existing infrastructures. Because value-based health care initiatives have bipartisan support, it is likely that these programs will continue to play a major role in both the public and private health insurance systems. As such, there is a pressing need to evaluate the implementation of these initiatives thus far and to discuss the direction that American health care financing will take in the coming years.
To explore this important issue, the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School collaborated with Ropes & Gray LLP to host a one-day conference on value-based health care. This event brought together scholars, health law practitioners, and health care entities to evaluate the impact of value-based health care on the American health care system.
For more information, visit our website at: http://petrieflom.law.harvard.edu/events/details/will-value-based-care-save-the-health-care-system
Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services.
These are in contrast to ad hoc committees, department and unit committees.
Financial Management In Healthcare PowerPoint Presentation SlidesSlideTeam
Presenting this set of slides with name - Financial Management In Healthcare Powerpoint Presentation Slides. This PPT deck displays fourty slides with in depth research. Our topic oriented Financial Management In Healthcare Powerpoint Presentation Slides presentation deck is a helpful tool to plan, prepare, document and analyse the topic with a clear approach. We provide a ready to use deck with all sorts of relevant topics subtopics templates, charts and graphs, overviews, analysis templates. Outline all the important aspects without any hassle. It showcases of all kind of editable templates infographs for an inclusive and comprehensive Financial Management In Healthcare Powerpoint Presentation Slides presentation. Professionals, managers, individual and team involved in any company organization from any field can use them as per requirement.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
A New Payer Model for Medical Management ExecutionCognizant
To combat rising costs and inefficient use of resources, payers can streamline utilization management and optimize care management through medical management delivered as a service.
Nursing Audit Dr. Rangappa. S .Ashi SDM Institute of Nursing sciences Shri D...rangappa
Nursing audit one of the control tools, responsible for controlling the activities of the nurses that focuses on providing the best possible nursing care. The actual nursing rendered is compared with the standards. This is mainly refers to clinical nursing audit. The nursing management audit is an evaluation of nursing management as a whole. It is critically examination of the entire nursing management process.
Utilization Management is an integral part of the US healthcare ecosystem used by health insurers or Pharmacy Benefit Managers (PBMs) to evaluate the appropriateness, medical necessity, and efficiency of healthcare services rendered to patients.
Strategies To Improve Authorization For Revenue Cycle Management.pdfCosentus
Healthcare is a very important sector for the world. While it takes care of patient health, there are numerous aspects involved to run a healthcare organization or provider. One of the important aspects is finance, which helps the healthcare organization get the right remuneration and help it function smoothly so that it is able to provide the best healthcare services to the patients. One of the important parts of the finance aspect of a healthcare organization is revenue cycle management. For more visit pdf
Main Value-Based Care Metrics for Healthcare PracticesPracticeBuilders2
In its essence, embracing value-based care requires a dedicated focus on carefully measuring and improving key performance metrics. By giving importance to healthcare performance measurement, physician performance metrics, and value-based care metrics, medical practices can pave the way for long-term excellence and innovation. https://www.practicebuilders.com/blog/value-based-metrics-for-healthcare-practices/
Transforming Clinical Practice InitiativeCitiusTech
The Transforming Clinical Practice Initiative (TCPI) is designed to help small practices and clinicians achieve large-scale health transformation. The initiative is designed to support more than 140,000 clinician practices over four years duration in sharing, adapting and further developing their comprehensive quality improvement strategies. The TCPI is one part of a unique strategy advanced by the Affordable Care Act to strengthen the quality of patient care and manage health care expenditures, ultimately saving the taxpayer from substantial costs. This document describes the initiative in detail with the type of participants, eligibility and reporting requirements of the participants. Understanding the implementation of this initiative not only helps clinicians, but opens up a huge market for Healthcare IT companies offering the products and services like EHR implementation, Integration, EHR/ Data Migration, Implementation of HIE etc.
Mastering Medical Credentialing The Essential Role Of Physician Credentialing...MedLifeMBS
In the intricate realm of healthcare administration, physician credentialing services stand as a cornerstone for ensuring the quality, credibility, and regulatory compliance of medical practitioners. From verifying credentials to facilitating provider enrollment, these services play a vital role in the seamless integration of healthcare professionals into the healthcare system. In this article, we delve into the importance of physician credentialing services, exploring their key functions, benefits, and best practices.
Mastering Medical Credentialing The Essential Role Of Physician Credentialing...
Utilization Management
1.
2. What is 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 applicable health benefits plan. Typically it includes new activities or
decisions based upon the analysis of a case.
The Institute of Medicine defines utilization management as “a set of techniques used by or on
behalf of purchasers of health care benefits to manage health care costs by influencing patient
care decision-making through case-by-case assessments of the appropriateness of care prior to
its provision”
Standard utilization management services include prospective review, concurrent review,
retrospective review, pre-certification of hospital stays, and discharge planning.
3. Purpose of a utilization management programme
To assure the effective and efficient utilization of hospitals, physician providers, facilities, case
management services, ancillary services and social services.
Services are medically necessary, delivered at an appropriate level of care, place of service and
consistent with criteria and clinical practice guidelines
To continually assess and improve as necessary, member access to care as well as quality of
care available to members.
To comply with local and regional healthcare delivery regulations and accreditations.
Under or over utilization of services is not occurring
To comply with local and regional healthcare delivery regulations and accreditations.
4. Benefits offered to a provider
Enhancing the standards and quality of care by providing medically necessary treatment to an
appropriate patient group after stratifying the medical risks and instituting timely therapeutic
interventions.
Multidisciplinary teams collaboration in designing appropriate care pathways, treatment
protocols, medical and surgical interventions for a patient group.
Reduction in Length of Stay (LOS) resulting in higher patient turnover leading to incremental
profits and a higher capacity.
Decreased health care spending in avoiding excessive use of healthcare resources without
yielding the desired benefit.
Tangible cost savings over a period of time by adhering to evidence-based clinical guidelines and
doing a periodic utilization review to achieve an optimum state of healthcare delivery.
Possible shift in clinical treatment philosophy from medical management to disease
management.
Efficient resource utilization and improved decision making in investments based on the current
utilization rates and patterns.
5. Guidelines
A utilization management programme in a hospital setting is based on the use of nationally
recognized
guidelines such as McKesson’s InterQual® Criteria or Milliman Care Guidelines®.
6. McKesson’s InterQual® Criteria
InterQual® clinical criteria and software is a market-leading solution that help payers and
providers determine the appropriate use of healthcare resources and improve the quality of care.
The InterQual suite helps payers, providers and other organizations share a common language for
determining the evidence-based clinical appropriateness of both medical and behavioral health
patient services, ranging from care settings to diagnostics and treatments.
InterQual® Acute Criteria enables the case manager to determine if the care is clinically indicated
and at the appropriate level of care.
Source: Mckesson website
7. McKesson’s InterQual® Criteria
InterQual helps to:
Reduce over- and under-utilization
i. Drive appropriate care with same source, rules-based, patient-specific EBM (evidence-based
medicine) decision support.
ii. Reduce re-admissions, LOS (length of stay) and services with integrated tools for complex and co-
morbid cases.
Increase defensibility and reduce risk
i. Validate appropriate care with quality indicators, checklists and reporting.
ii. Drive cost efficiencies through Clear Coverage™, the InterQual auto authorization solution.
Align stakeholders
i. Drive consistency with same source, rules-based, customizable EBM decision support.
ii. Align with CMS guidelines.
iii. Reduce administrative expense with fewer denials and appeals.
iv. Improve quality with more time available for patient care.
Support stakeholder performance management
i. Facilitate medical and payment policy decisions with rules-based EBM.
ii. Identify practice trends and areas for quality improvement.
iii. Identify high-quality, high-performing providers for ‘gold-carding’ and tiered networks.
Source: Mckesson website
8. Milliman Care Guidelines®
Milliman Care Guidelines are evidence-based clinical guidelines including care pathways that
help providers and payors in effective decision making for the patient care. Milliman Care
Guidelines® are annually updated, evidence-based clinical guidelines that span the continuum of
care, including chronic care and behavioral health management.
They are either client-hosted or web-based software that readily interfaces with many medical
management and clinical information systems. Interactive version CareWebQI® enables quality
improvement and cost efficiency through targeting and reducing inappropriate care. It helps in
identifying gaps in care and cause of variation thus reducing their occurrences.
Indicia® for Utilization Review helps clinical teams make admissions decisions and utilization
managers justify admissions, level-of-care assignments, and procedures to safeguard
reimbursements and meet the challenges of RAC audits.
Source: Milliman website
9. Overview of a Utilization Management Programme
Any Utilization Management programme’s mission is to provide a decision support system for
clinicians and managers. It may provide feedback on service utilization to clinicians and managers on
behalf of clients. The programme intends to monitor and report on system wide service utilization
patterns. It may also provide concurrent utilization review of individual client service needs.
UM Plan Clinical Tools
Clinical (Medical) Necessity Criteria (Services recommended in the treatment plan
must meet all of the following criteria)
1. Treatment must be no more and no less than the client requires based on diagnosis/symptoms/
behaviors/skills/abilities/functioning
2. Treatment is safe and effective according to national standards
3. Treatment is in the least restrictive setting
4. Treatment is cost effective
Source: UM Plan for DuPage County Mental Health
10. Utilization Review
Utilization Review is a process used to evaluate requested health care services and determine if they
are Medically Necessary.
It is usually of following types:
i. Prospective Review
ii. Concurrent review
iii. Retrospective review
Role of Utilization Review is to validate:
the necessity of medical service requested
if the duration of service requested is within the prescribed range
the amount or intensity of service required is appropriate in a given situation
12. Outcomes of Utilization Management
Possible enhancement of quality and effectiveness of patient care
Possible reduction in ALOS leading to increased profitability
Improved healthcare outcomes for the patients providing positive brand
value to the provider
Predictability in care pathways and treatment measures instituted
Reduction in revenue leakages and aligning investment decisions more
towards future costs and business efficiency
Enhancing competitiveness of the provider