utilization management

The healthcare system is a crucial component to the health of communities. The United States is the only industrialized and wealthy country in the world without a universal healthcare system, which perhaps makes the understanding of healthcare practices difficult for the average American can understand. Healthcare can be kind of a buzzword for some. It is confusing, expensive and out of reach for many. Studies show that after the passage of the Affordable Care Act (or the ACA) in 2009, more than 20 million Americans who were previously uninsured, received healthcare coverage. This is good news because studies also show that Americans without health insurance are more costly to the American government. Why is that? It’s because without the preventative services that health insurance allows (and many insured people utilize), uninsured people are not aware of any conditions they may have, meaning they are more likely to seek costly emergency room services for emergency situations.

In order to ensure the healthcare system runs as efficiently as possible for both users and purchasers of insurance, many companies have utilization management services, which takes some of the guesswork out of the equation. This service uses a set list of criteria to determine what kind of procedures and treatments should be administered based on the provisions set out by the users insurance. This helps purchasers of insurance get a better handle of overall costs.

For example, utilization management takes a close look at what patients need on a case by case basis and works to determine how this can change daily based on cost versus necessity. In order to be as objective as possible, there are three ways that utilization management services can take place. The first is prospectively, which takes a look at a case before the fact and helps determine whether certain procedures or even patient admission is necessary based on predetermined criteria. The next way is concurrently, which means the review is taking place while the patient is being treated and can be examined on a day by day basis. The final way is retrospectively, which means that the review occurs after the patient has been treated and determines if the right decisions were made at all points of care. Retrospective review uses the same set of criteria and guidelines and could possibly affect submitted billing or claims. In addition though, it helps refine guidelines for other similar cases in the future.

Access to appropriate healthcare is a concern for many Americans. Studies show that as recently as 2010, nearly 50 million Americans were without health insurance coverage. About 50 percent of those people stated that the reason they were uninsured was because of the cost barrier. In order to make heathcare accessible, it must be affordable, so it makes sense that frequent reviews of utilization are done to look at cost and necessity in the numerous cases that come across clinics, hospitals and more. With a better understanding of healthcare costs and the needs of the people utilizing the care, the healthcare system can thrive.