Running head CHALLENGES IN UTILIZATION AND CASE MANAGEMENT IN MAN.docx

Running head: CHALLENGES IN UTILIZATION AND CASE
MANAGEMENT IN MANAGED CARE
1
CHALLENGES IN UTILIZATION AND CASE
MANAGEMENT IN MANAGED CARE 3
Challenges in Utilization and Case Management in Managed
Care
Leribeth Inoa
2/23/2019
Managed care refers to the practice of managing some
aspects of the medical services i.e. the cost and the quality of
the medical services. Managed care can be managed by
healthcare providers when providing healthcare services.
Utilization management refers to the processes or the activities
that are involved in the management of care. for example
Uutilization management is relied on in terms of managing the
cost in the health plan. It also refers to the routine functions
which are utilized for the management of the cost of the medical
services. Utilization management is entailing aspects such as
prospective, concurrent, and the retrospective review. A
prospective review is involving the process of tackling the
utilization before its occurrence; con-current review is

addressing the utilization as it happens; whereas the
retrospective review occurs after the fact. Case management, on
the other hand, is relied on in delivering substantial savings. In
case of management, trained nurses are relying on the nurses to
help in the coordinating the aspects of care like rehabilitation,
home care, and health education thus helping in the
improvement of the outcomes and the reduction of the expenses
(Peter, 2019). Comment by Susan Such: I think I know what
you are trying to say but you should rework the sentence. You
might indicate that “managed care guidelines are adhered to by
providers”. The providers don’t actually manage managed
care, but they are subject to the rules of it. Comment by
Susan Such: I think you could do better with this in terms of
explaining the meaning. Comment by Susan Such: Process as
you wrote it is singular, activities is plural. When you then
have to figure out to use is or are you have an issue. Both have
to be either singular or plural. Comment by Susan Such: End of
sentence. Begin the next sentence with Utilization management
is relied on…… Comment by Susan Such: This pretty much
duplicates the previous sentence Comment by Susan Such:
Aspects of utilization management are prospective, concurrent,
and retrospective review. Comment by Susan Such:
Explain with a bit more details. What is being reviewed??
Comment by Susan Such: In case management specially
trained nurses rely on the staff nurses to help…… Comment by
Susan Such: Comment by Susan Such: Is this the one
paragraph introduction? There should be a paragraph that
explains what the paper is intending to accomplish or teach, etc.
I would say that the paragraph here is explaining your topic.
But you don’t have an introduction.
Challenges in Utilization and Case Management in Managed
Care
Utilization management is considered to process which
have been well thought-out to help in the controlling of the
medical services which are being provided by other people.
Utilization management is a growing technique for quality

assurance and for the containment of the cost. Managed care is
an important aspect since it is directly affecting the quality as
well as the availability of the medically required treatment. It is
also important in discharging the plans, managing of the
catastrophic cases, and the performance of other healthcare
reviews (Peter, 2019). Comment by Susan Such:
Introduction: Students will submit a one paragraph introduction
of the topic they will be discussing.
Body of the Paper will include the following.
Explain your topic in detail.
Define the Challenges and Problems with your topic.
What are recommended solutions to the challenges and
problems?
Are there any implementation to solve the challenges and
problems?
What is your opinion on the topic and what would you do if you
were in charge to fix the problem.
Conclusion
Work Cited in APA format. Students will have at least two
references.
Case management is targeting the high cost as well as the
restrained to high-risk patients who consume a uneven amount
of healthcare resources. Effective case management programs
have become increasingly essential within the system of
healthcare. This is because it is greatly impacting on a number
of factors such as the aging population, the readmission
penalties, and the increasing quality reporting requirements, the
expanded health insurance cover, and the payment reforms
among others (Peter, 2019).
The challenges Comment by Susan Such: You don’t need
this. It falls under the main heading.
Despite the importance of the two factors i.e. utilization
and the case management, there are a number of challenges
which are faced towards the success used of these two aspects
in the managed care. Utilization management is having a

challenge which is related to the limited clinical autonomy as
well as being the contributory factor to the intolerable
administrative burden. Some of the issues related to the
utilization management are in the pharmacy whereby there is an
increased risk sharing which made to be complex by the delays
in the data flow and the complicated financing for example
rebates to the pharmacy benefit managers which might or might
not be shared with the vendors. There are also problems which
are related to the communication process between the groups
and the clinical providers concerning drug utilization
(Flemmons & Wyatt, 2015). Comment by Susan Such: Is this
taken from the source? What does it mean Comment by
Susan Such: Because you don’t have an introduction indicating
what you are trying to state, with this paper, the body of the
paper and its meaning, gets lost. So you need to pull it together
and ensure your sentences make sense.
Another challenge of the utilization management in the
pharmacy benefit managers is the variations in the quality
which occasionally leads to the low plan STAR ratings. There is
a variation in the formularies and the distribution channels of
the drugs. There is also limited best patient pricing to a single
chain. There are no alternatives for the integration with other
sources of drug therapy. Tiered reimbursement and prior
authorizations for the specialty as well as the high-risk drugs
leads to negative impact adherence and timely access. Another
challenge is related to the drug reconciliation more so at the
transition in care from outpatient to the institution and back
(Spetz, 2015). Comment by Susan Such: You’ve done a
great job with the intext citations. If there are page numbers to
supply you want to add that too.
With regard to the case management, managers are faced
with difficulties as well as with multifactorial responsibilities
which are focused on the means of preventing, proactive
interventions, and the transitions of the care. Managers are
responsible for the facilitation of the care to the complex
patients, for example, those who are having prolonged co-

morbid illnesses and require psychosocial help, coordination of
care to guarantee eminence outcomes in the highest operational
fashion, reduction of the preventable hospital admissions, and
reducing the gaps among others. Therefore, it is always the
responsibilities of these managers to access timely data and
insights with regard to the status of the patients (Spetz, 2015).
Another challenge in relation to the case management is
related to the misalignment of the financial incentive. There is
an increase in the site of the service reimbursement between the
provision by the healthcare outpatient clinics and the non-
healthcare private practice providers. This means that there is a
possibility of having lower cost care to ensure equal quality
thus leading to the reduction of the revenues of the case
manager's employers (Flemmons & Wyatt, 2015).
With regard to the case and the utilization management
devoid of timely and information-driven acumens of the limited
value, there are some substantial investments which have been
made in terms of the electronic healthcare record systems which
are used for the administration, financial, and the operational
functionality of the organization. These incentives are
important, nevertheless, there are challenges with regard to the
interoperability with the legacy and other information
technology systems. Rather than helping in the improvement of
physician productivity, electronic medical records are becoming
more focused on the administrative activities, ancillary staff,
layings-off, and billing.
Recommended solutions
To address the challenges related to utilization
management, it is important to have an effective solution so that
there can be a successful process of managing care. In this case,
it is important to have committed primary care physicians who
are already practicing the primary care Medical Home Model to
help in supporting the medical group. This can be achieved
through having team-based care, all the team members working
to the highest level of their education and licensure, the
existence of robust communication systems with the patients

prior to, during, and after the in-person office visits. It is also
important to have a data system with Electronic Medical Record
to help in the identification of the present gaps in the care,
preventive requirements, and clinical pathways. Assessment in
the transparency of the data related to the outcomes is important
since it supports the improvement.
It is also important to have a committed network of
healthcare providers from the institution to the consultant
specialists. It is necessary to have prayer partners who can share
accurate as well as timely data from the separate utilization
management activities more pharmacy and the behavioral health
and from the claims. With regard to case management, it is
necessary to have human capital approaches. Some of the human
capital approaches which are applicable include leadership, the
recruitment process, development of the organization, and the
optimization of the performance among employees. Proactive
partnership amongst the patients, financiers, primary care
physicians, and clinical specialists is essential.
The use of a supportive cloud-based technique, data
analytics, and the governing acquiescence mechanism also
forms important elements of human capital strategies which can
be used to overcome the issues related to the case management
in the managed care. An organization can also rely on the A &
M's clinical support services practice to help in giving
registered nurses with leadership and staff status in the
utilization and case management. This is important in ensuring
that there is the existence of personnel who can be contacted for
short-term operational and the long-term strategic needs of the
organization (Spetz, 2015).
Whether there is a presence of the implementation processes
towards addressing the challenges and problems
There is pharmacy Benefit Managers who are responsible
for making direct contact with the payer and they rarely take
financial risks for the cost of the drug benefit. The pharmacy
benefit managers' services are included in the overall
administrative services for the individual funded plans.

Utilization management is relying on or making claims of the
data from the pharmacy benefit managers to ensure that there is
effective management of the programs (Peter, 2019).
There is the presence of the peer review which is important
for the establishment of the policies and the procedures to help
in the assessment of the potential service or quality issue in
relation to the specific providers. The policies are majorly
concerning the process of care and in this case, members plans
in the network provider or applying to credentialing and re-
credentialing process. Peer review also involves policies and
procedures related to the internal information collection which
are specific to the provider.
Reflection or opinion on the topic
Utilization management and the case management in the
managed care are important processes which are necessary for
ensuring that there is success management process of the
medical services. Usually, managed care is an important issue
which is affecting the quality as well as the availability of the
medically required treatment. When faced with the situation or
issues related to the cost management in the firm. It is always
important to ensure that the processes involving the utilization
and case management are monitored are effectively managed to
ensure that the cost of health care is managed effectively. A
suitable process of implementing the utilization and case
management is important when it comes to the balancing of the
clinical needs of the patients. One of the mechanisms through
which the success of the utilization and case management are
achieved is ensuring that there is the existence of better design
plan to help in the redistribution of the resources which are
targeted at facilitating inpatient, residential, inpatient, and day
hospital treatment.
Conclusions
It is important to make an effort towards the management
of the cost. It is important to acquire a better price for medical
services to help in the control of the cost. The success process
of controlling the cost requires a combination of utilization

management and care management. Utilization management
involves the aspects of prospective, concurrent, and the
retrospective review. A prospective review is involving the
process of tackling the utilization before its occurrence; con-
current review is addressing the utilization as it happens;
whereas the retrospective review occurs after the fact. Case
management, on the other hand, is relied upon towards
delivering substantial savings.
References
Flemmons, K., & Wyatt, P. (2015). Utilization Management:
CMS Guidelines for Observation and Inpatient Services.
Presentation from Vanderbilt University Medical Center.
Peter, K. (2019). Utlization Management, Quality Management,
and Accreditation. Health Insurance and Managed Care, 153-
190.
Spetz, J. (2015). Too Many, Too Few, or Just Right? Making
Sense of Conflicting RN Supply and Demand Forecasts.
NURSING ECONOMIC, 33(3), 177.
2/21/2019 Page 157, Health Insurance and Managed Care, 4e
https://berkeley.courseload.com/#/content-44695/address/177
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