Utilization Review and Quality Management Utilization review is a process that insurance companies utilize to determine if a treatment is appropriate and review the request for the treatment. Quality management is a service that ensures an organization’s services is consistent. The key elements in utilization review “The purpose of the review is to confirm that the plan provides coverage for your medical services. It also helps the company minimize costs and determine if the recommended treatment is appropriate.” (Garden and Insurance, 2018) Typically utilization review involves the review of past medical history. Utilization review helps insurance companies create guidelines on treatment for conditions. This process helps determine the most …show more content…
Quality management procedures are in place to reduce waste, lower costs, engage staff, and identifying training opportunities. (Asq.org, 2018) This system is in place to ensure patient satisfaction. Quality management is in place to make sure patients receive the highest quality of care and treatment. In most states, HMOs and POS plans are required to have quality management programs. There are three major categories of quality management Donabedian’s classic model of quality management. This model consists of structure, process, and outcome. Quality management also consists of 6 goals, safe, effective, patient-centered, timely, efficient, and equitable. These goals were created by the Institute of medicine. According to page 180 of Health Insurance and Managed Care many HMOs have worked to incorporate these goals but these goals are provider oriented. One of the key elements of quality management is structure. The structure is about the context that care is …show more content…
They both are utilized to make sure patients receive proper and high-quality care. Utilization reviews focus on the quality of care and quality management focuses on how the patients receive care. They are similar because they both focus on the care of the patients. Both quality management and utilization review are utilized to assist in determining what insurance companies will cover for treatment, and if the treatment is successful. Both quality management and utilization review are used by insurance companies. They are different because they are different processes. They focus on different aspects of treatment, care, and common diseases. Another thing that makes them similar is that they both of have changed over