Utilization Review and Quality Management

Jamie B
Learning Plan 3
April 5, 2015
Utilization Review and Quality Management

Utilization management and care management is the practice of managing medical services utilization. There are many key elements within utilization management, which are in place to help control medical costs. Prior to managed health care, controlling the cost was mainly done by cost sharing between the insurance companies and the members or the contracts that they had with providers.
There are multiple key elements within utilization management, the first being basic utilization management. Basic utilization management deals with the most common medical services and how the managed care organization controls those costs. Perspective utilization managements is another element that is separated into three different categories, demand management, referral management and precertification of institutional services. Concurrent utilization management applies mostly to inpatient services as well as the complex and expensive cases. Concurrent utilization management is also known as continued stay review. Retrospective utilization management is separated into two different categories, case review and pattern analysis.
As stated, prospective utilization management is broken down into three different categories; demand management is there to help influence the future demand of medical services. These services would include things such as access to preventive services for the members, more convenient hours so members can find time to receive their services as well as informational brochures that members are able to take home. Some managed care organizations may even provide a live nurse line that members may call into to get advice from a trained nurse to possibly avoid needing to go into the clinic all together. It also appears that some organizations that use the nurse line seen a decline of the emergency room services.
Referral management is used for primary care providers to refer patients out to specialists for services that are deemed as medically necessary, which helps eliminate overuse. If the primary care provider determines that a patient needs to see a specialist for a condition that they cannot treat they will then authorize a referral to a specialist that is also in contract with the managed care organization. Primarily this is always completed by the primary care provider and the managed care organization rarely gets involved.
Precertification of institutional services is something for both inpatient as well as outpatient services. The provider typically contacts the managed care organization for said certification and the managed care organization then checks their guidelines and clinical criteria to verify that the services would be medically necessary or not and then either authorizes the procedure to be completed or they deny it. If the precertification is not obtained the member or provider gets penalized. If it was the patient’s responsibility to complete the precertification and they do not do so the services may be not covered or there may be a higher cost sharing on the patients end. If the provider is the one who should have recertified the services and did not compete it, it may be denied for the provider’s responsibility.
As stated, retrospective utilization management is broken down into case review and pattern analysis. Case review is when past cases are reviewed to verify appropriate care was given, billing errors or any other issue that may arise, even making sure that the providers are not committing fraud. Pattern analysis is reviewing utilization data to determine if there are any patterns that arise. The patterns may be specific to one provider or they may be found plan wide. If there is a pattern that if found, it must be investigated so that appropriate actions may be taken to correct the pattern.
Quality management has external accreditation agencies that verify that the managed care organization is meeting the standards for measuring and improving the quality of the services it provides. The classic approach to quality management is based off of three key elements, structure, process and the outcome.
Structure of quality care is to look at the infrastructure of the managed care organization and it’s quality and to make sure that it makes the appropriate changes to bring out the best quality improvements, this may be completed by reviewing clinical notes, medical records, and responses to patients and so forth. Process is the actual care that is rendered. This is when medical records are reviewed and making sure that providers are following the proper steps for rendering such services. Some larger managed care originations have started completing the process by means of a review completed by using technology to trace diagnosis on discharge and so forth. To evaluate the outcome, managed care organizations look at adverse events, such as making sure that the events called “never events” do not occur. These never events would be situations in which the provider may have made some costly errors that should never occur. Some of these errors may include a possible item left behind in the patient after surgery or amputation of the incorrect limb and even dispensing the incorrect prescription to the patient. The quality management committee is responsible to make choose which type of outcomes need to be measured and how to determine if the outcome was successful.
There is total quality management as well and that is more in place to make sure that the standards are improving. Quality care is there to make sure that providers are conforming to the standards, whereas total quality management holds its importance in finding new ways to improve those standards.
Utilization management and quality care both play a major role in managed care. Utilization management is there to help control costs and quality care is there to make sure standards are met and improving. Without these two elements of managed care, cost may be hard to control. Patients may seek services that are not medically necessary or providers may requests services that are not medically necessary to be completed. Utilization management is there to make sure that services are medically necessary. Quality care is also an important role due to the fact that it makes sure that providers are following the standards of operations and that they are always looking for improvement. Making sure that providers are following the standards of quality care also helps reduce cost of medical services by helping to eliminate patients coming back for the same services again after a surgery or procedure may have failed. In a whole, I believe both managed care and quality care play a very important role in the managed care systems.
Kongstvedt, P. (2009). Managed care: What it is and how it works (3rd ed.). Sudbury, Mass.: Jones and Bartlett.