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Utilization Management Case Study

568 Words3 Pages

Utilization management (UM) is one of the fundamental strategies used by MCOs to evaluating the appropriateness of care and service and the existence of coverage. Utilization management for all intentions incorporates prospective, current and retrospective actives or reviews. The prospectus review influences the utilization of care, service or benefits before the fact; while current review influences ongoing utilization. Lastly, the retrospective review involves the use of case study and utilization pattern to determine areas in need of improvement within the MCOs.
As stated above a prospective utilization management influences utilization prior to care or service. A managed care organization can achieve an excellent prospective utilization management through the efficient use of the concept of demand management, referral management, and precertification. The demand management enables the MCOs to influence the future demand for care by continually improving members access to benefits such preventative services , convenient hours of operations, utilization concept education for all MCOs’ beneficiaries and care delivery personnel etc. …show more content…

It is worth mentioning that, the various MCOs have set referral or precertification policies and procedures based on the type of plan purchased by their respective beneficiaries. For example, not obtaining authorization prior to admission or procedure will result in members accumulating stipulated penalties set forth by the respective management care organization. However, the exception would be emergency situations as postulated by the individual

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